Provider Demographics
NPI:1659644045
Name:PRESTIGE MEDICAL SERVICES & REHAB CENTER LLC
Entity Type:Organization
Organization Name:PRESTIGE MEDICAL SERVICES & REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:NEREIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:INFANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-897-1135
Mailing Address - Street 1:2614 E COLONIAL DR
Mailing Address - Street 2:SUITE 400-5
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5028
Mailing Address - Country:US
Mailing Address - Phone:407-897-1135
Mailing Address - Fax:407-897-1136
Practice Address - Street 1:2614 E COLONIAL DR
Practice Address - Street 2:SUITE 400-5
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5028
Practice Address - Country:US
Practice Address - Phone:407-897-1135
Practice Address - Fax:407-897-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC9454261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGM816AOtherMEDICARE PTAN
FL008337700Medicaid