Provider Demographics
NPI:1609045756
Name:LYMPHEDEMA TREATMENT CENTER LLC
Entity Type:Organization
Organization Name:LYMPHEDEMA TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARSHA
Authorized Official - Last Name:CORRALES
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:904-425-4391
Mailing Address - Street 1:11512 LAKE MEAD AVE UNIT 604
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9686
Mailing Address - Country:US
Mailing Address - Phone:904-425-4391
Mailing Address - Fax:904-425-4392
Practice Address - Street 1:11512 LAKE MEAD AVE UNIT 604
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9686
Practice Address - Country:US
Practice Address - Phone:904-425-4391
Practice Address - Fax:904-425-4392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12323225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty