MEDICARE: SUSTAINABLE REHABILITATION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1962245274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSTAINABLE REHABILITATION LLC

Provider Business Mailing Address
First Line	:	17 LAKESIDE PL W
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-3415
Country	:	US
Telephone Number	:	775-343-9322
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 LAKESIDE PL W
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-3415
Country	:	US
Telephone Number	:	775-343-9322
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARCA ALEXANDER
Credential	:	MD
Telephone Number	:	775-343-9322

Provider Enumeration Date	:	06/14/2024
Last Update Date	:	06/20/2024

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