Provider Demographics
NPI:1447206917
Name:AVA REHABILITATION CLINIC
Entity Type:Organization
Organization Name:AVA REHABILITATION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:POLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYED
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:863-676-8300
Mailing Address - Street 1:1342 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4322
Mailing Address - Country:US
Mailing Address - Phone:863-676-8300
Mailing Address - Fax:863-676-1300
Practice Address - Street 1:1342 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4322
Practice Address - Country:US
Practice Address - Phone:863-676-8300
Practice Address - Fax:863-676-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT3913174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD6113OtherRAILROAD MEDICARE
DD6113OtherRAILROAD MEDICARE