Provider Demographics
NPI:1477574655
Name:REHAB SOURCE P A
Entity Type:Organization
Organization Name:REHAB SOURCE P A
Other - Org Name:COLLIER PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PAGKANLUNGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-643-7879
Mailing Address - Street 1:6825 DAVIS BLVD APT 257
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34104-5326
Mailing Address - Country:US
Mailing Address - Phone:239-643-7879
Mailing Address - Fax:239-643-2951
Practice Address - Street 1:6825 DAVIS BLVD
Practice Address - Street 2:#157
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34104-5331
Practice Address - Country:US
Practice Address - Phone:239-643-7879
Practice Address - Fax:239-643-2951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0007692225100000X
FLPT0008895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY018NOtherBLUECROSS/BLUESHIELD #
FLY036QOtherBLUECROSS/BLUESHIELD#
FLY036QOtherBLUECROSS/BLUESHIELD#
FLU0672ZMedicare ID - Type UnspecifiedMEDICARE NUMBER
FLK4294Medicare ID - Type UnspecifiedGROUP NUMBER