Provider Demographics
NPI:1275188849
Name:PRACTICAL REHAB LLC
Entity Type:Organization
Organization Name:PRACTICAL REHAB LLC
Other - Org Name:PHYSIOCARE SPORT & SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-395-0018
Mailing Address - Street 1:4019 HENDERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-4939
Mailing Address - Country:US
Mailing Address - Phone:813-395-0018
Mailing Address - Fax:917-601-7515
Practice Address - Street 1:4019 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-4939
Practice Address - Country:US
Practice Address - Phone:813-395-0018
Practice Address - Fax:917-601-7515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty