Provider Demographics
NPI:1609103993
Name:FUNCTIONAL REHAB INC
Entity Type:Organization
Organization Name:FUNCTIONAL REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:NOSTER
Authorized Official - Middle Name:R
Authorized Official - Last Name:VILLAMOR
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:863-441-1226
Mailing Address - Street 1:123 US 27 S
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-7918
Mailing Address - Country:US
Mailing Address - Phone:863-441-1226
Mailing Address - Fax:863-465-7790
Practice Address - Street 1:123 US 27 S
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-7918
Practice Address - Country:US
Practice Address - Phone:863-441-1226
Practice Address - Fax:863-465-7790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-09
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT7249261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1609103993Medicare PIN