Provider Demographics
NPI:1609145580
Name:PHYSICAL MEDICINE & REHAB OF BREVARD, P.A.
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE & REHAB OF BREVARD, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-449-1112
Mailing Address - Street 1:840 EXECUTIVE LN STE 120
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3519
Mailing Address - Country:US
Mailing Address - Phone:321-449-1112
Mailing Address - Fax:321-449-1172
Practice Address - Street 1:840 EXECUTIVE LN STE 120
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3519
Practice Address - Country:US
Practice Address - Phone:321-449-1112
Practice Address - Fax:321-449-1172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE35821Medicare UPIN