Provider Demographics
NPI:1730295247
Name:ADVANCED REHAB CENTER INC
Entity Type:Organization
Organization Name:ADVANCED REHAB CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:312-383-0889
Mailing Address - Street 1:4401 S HOPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6679
Mailing Address - Country:US
Mailing Address - Phone:321-383-0889
Mailing Address - Fax:321-383-0898
Practice Address - Street 1:4401 S HOPKINS AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-6679
Practice Address - Country:US
Practice Address - Phone:321-383-0889
Practice Address - Fax:321-383-0898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16170.1OtherHEALTH FIRST HEALTH PLAN
FLY083UOtherBCBSF
FL9407570OtherPRIVATE HEALTH CARE
FL23906OtherSOUTH CARE
FL23906OtherSOUTH CARE
FL16170.1OtherHEALTH FIRST HEALTH PLAN