Provider Demographics
NPI:1730479601
Name:PHYSICIAN REHAB CENTER INC
Entity Type:Organization
Organization Name:PHYSICIAN REHAB CENTER INC
Other - Org Name:ACESO & PANACEA WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY/VP
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-213-4211
Mailing Address - Street 1:5801 NW 151ST ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2437
Mailing Address - Country:US
Mailing Address - Phone:305-828-0455
Mailing Address - Fax:305-828-8455
Practice Address - Street 1:5801 NW 151ST ST
Practice Address - Street 2:SUITE 106
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2437
Practice Address - Country:US
Practice Address - Phone:305-828-0455
Practice Address - Fax:305-828-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME17907208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty