Provider Demographics
NPI:1144288986
Name:FLORIDA THERAPY CENTER OF MELBOURNE LLC
Entity type:Organization
Organization Name:FLORIDA THERAPY CENTER OF MELBOURNE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:SIMON
Authorized Official - Last Name:KRONMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:321-890-7439
Mailing Address - Street 1:635 S WICKHAM RD STE 103
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1436
Mailing Address - Country:US
Mailing Address - Phone:321-890-7439
Mailing Address - Fax:321-768-1710
Practice Address - Street 1:635 S WICKHAM RD STE 103
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1436
Practice Address - Country:US
Practice Address - Phone:321-890-7439
Practice Address - Fax:321-768-1710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGF7OtherBCBS PROVIDER NUMBER
FLGF7OtherBCBS PROVIDER NUMBER
FL=========OtherTAX ID NUMBER