Provider Demographics
NPI:1073536413
Name:INDEPENDENCE REHAB LLC
Entity Type:Organization
Organization Name:INDEPENDENCE REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:EDUARDO
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:863-409-6481
Mailing Address - Street 1:5241 NICHOLS DR E
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4077
Mailing Address - Country:US
Mailing Address - Phone:863-409-6481
Mailing Address - Fax:
Practice Address - Street 1:5241 NICHOLS DR E
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-4077
Practice Address - Country:US
Practice Address - Phone:863-409-6481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT7865320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4600Medicare UPIN