Provider Demographics
NPI:1558495259
Name:PARTNERS IN HEALTH F.O.R.M.E MEDICAL AND REHAB CENTERS, INC
Entity Type:Organization
Organization Name:PARTNERS IN HEALTH F.O.R.M.E MEDICAL AND REHAB CENTERS, INC
Other - Org Name:PARTNERS IN HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SANON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:305-758-7979
Mailing Address - Street 1:9730 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2311
Mailing Address - Country:US
Mailing Address - Phone:305-758-7979
Mailing Address - Fax:305-758-0034
Practice Address - Street 1:9730 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-2311
Practice Address - Country:US
Practice Address - Phone:305-758-7979
Practice Address - Fax:305-758-0034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7398111N00000X
FLCH9614111N00000X
FLME26113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258983400Medicaid
FL258983400Medicaid
55776Medicare PIN