Provider Demographics
NPI:1073918371
Name:PAIN AND SPINE PHYSIO REHAB LLC
Entity Type:Organization
Organization Name:PAIN AND SPINE PHYSIO REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINO IRWIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:518-407-3422
Mailing Address - Street 1:100 SOUTHPARK BLVD
Mailing Address - Street 2:SUITE 408-B
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5189
Mailing Address - Country:US
Mailing Address - Phone:518-407-3422
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTHPARK BLVD
Practice Address - Street 2:SUITE 408 B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5189
Practice Address - Country:US
Practice Address - Phone:518-407-3422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-29
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT7862225100000X
FLPT0007862261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIB887AMedicare PIN