Provider Demographics
NPI:1750504957
Name:FAMILY REHAB CLINIC
Entity Type:Organization
Organization Name:FAMILY REHAB CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORREIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:598-260-4227
Mailing Address - Street 1:231 MAIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4342
Mailing Address - Country:US
Mailing Address - Phone:508-587-0404
Mailing Address - Fax:508-587-0458
Practice Address - Street 1:231 MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4342
Practice Address - Country:US
Practice Address - Phone:508-587-0404
Practice Address - Fax:508-587-0458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization