Provider Demographics
NPI:1578935763
Name:OVERLORD LLC
Entity Type:Organization
Organization Name:OVERLORD LLC
Other - Org Name:OVERLORD REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JARNAGIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:386-315-0778
Mailing Address - Street 1:1208 N HALIFAX AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-3657
Mailing Address - Country:US
Mailing Address - Phone:386-315-0778
Mailing Address - Fax:386-872-5671
Practice Address - Street 1:523 MAGNOLIA TRACE BLVD
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2389
Practice Address - Country:US
Practice Address - Phone:386-315-0778
Practice Address - Fax:386-872-5671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty