Provider Demographics
NPI:1013199751
Name:ISLAND REHABILITATION CENTER
Entity Type:Organization
Organization Name:ISLAND REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF ISLAND REHABILITATION
Authorized Official - Prefix:MR
Authorized Official - First Name:CHULANI
Authorized Official - Middle Name:K
Authorized Official - Last Name:FERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MA, BSC, FAAPM,
Authorized Official - Phone:239-394-4135
Mailing Address - Street 1:19 BALD EAGLE DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-3580
Mailing Address - Country:US
Mailing Address - Phone:239-394-4135
Mailing Address - Fax:239-394-6921
Practice Address - Street 1:19 BALD EAGLE DR
Practice Address - Street 2:SUITE F
Practice Address - City:MARCO ISLAND
Practice Address - State:FL
Practice Address - Zip Code:34145-3580
Practice Address - Country:US
Practice Address - Phone:239-394-4135
Practice Address - Fax:239-394-6921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL980018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106580Medicare Oscar/Certification