Provider Demographics
NPI: | 1508539586 |
---|---|
Name: | IMPRESSION HOME HEALTHCARE & THERAPY |
Entity Type: | Organization |
Organization Name: | IMPRESSION HOME HEALTHCARE & THERAPY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MANAGING DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ROSEGUENE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | STEPHEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 561-860-1339 |
Mailing Address - Street 1: | 6258 WAUCONDA WAY W |
Mailing Address - Street 2: | |
Mailing Address - City: | LAKE WORTH |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33463-5870 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 561-860-1339 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1701 N 14TH ST |
Practice Address - Street 2: | |
Practice Address - City: | FORT PIERCE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34950-2113 |
Practice Address - Country: | US |
Practice Address - Phone: | 561-206-2289 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-07-27 |
Last Update Date: | 2022-08-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | Group - Multi-Specialty |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 2081P0010X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pediatric Rehabilitation Medicine | Group - Multi-Specialty |
No | 2081S0010X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | Group - Multi-Specialty |
No | 225700000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | Group - Multi-Specialty | |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
No | 251B00000X | Agencies | Case Management | Group - Multi-Specialty | |
No | 251K00000X | Agencies | Public Health or Welfare | Group - Multi-Specialty | |
No | 252Y00000X | Agencies | Early Intervention Provider Agency | Group - Multi-Specialty | |
No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | Group - Multi-Specialty |
No | 261QR0400X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | Group - Multi-Specialty |
No | 261QX0100X | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 111802300 | Medicaid |