Provider Demographics
NPI:1649380411
Name:INTEGRATED REHAB. PA
Entity Type:Organization
Organization Name:INTEGRATED REHAB. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NILES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MS, CSCS
Authorized Official - Phone:954-816-1029
Mailing Address - Street 1:2180 SW 115TH TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-4854
Mailing Address - Country:US
Mailing Address - Phone:954-816-1029
Mailing Address - Fax:954-577-3444
Practice Address - Street 1:2180 SW 115TH TER
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33325-4854
Practice Address - Country:US
Practice Address - Phone:954-816-1029
Practice Address - Fax:954-577-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7110Medicare PIN