Provider Demographics
NPI:1396016606
Name:SOUTH REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:SOUTH REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEDRIX
Authorized Official - Middle Name:
Authorized Official - Last Name:DAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-423-0017
Mailing Address - Street 1:580 ELLIS RD S STE 118
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3567
Mailing Address - Country:US
Mailing Address - Phone:904-423-0017
Mailing Address - Fax:904-683-8169
Practice Address - Street 1:3975 S ORANGE BLOSSOM TRL STE 105
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-7905
Practice Address - Country:US
Practice Address - Phone:407-601-4929
Practice Address - Fax:407-730-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011926000Medicaid
FL004720700Medicaid
FL004720700Medicaid
FL011926000Medicaid