Provider Demographics
NPI:1649590092
Name:FOUNTAINBLEAU REHAB CORP
Entity Type:Organization
Organization Name:FOUNTAINBLEAU REHAB CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:COFINO
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:305-552-5554
Mailing Address - Street 1:PO BOX 228653
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33222-8653
Mailing Address - Country:US
Mailing Address - Phone:305-552-5554
Mailing Address - Fax:305-552-5564
Practice Address - Street 1:175 FONTAINEBLEAU BLVD
Practice Address - Street 2:SUITE 2G-10
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-7018
Practice Address - Country:US
Practice Address - Phone:305-552-5554
Practice Address - Fax:305-552-5564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty