Provider Demographics
NPI:1770510216
Name:ST LOUIS REHABILITATION PROGRAM INC.
Entity Type:Organization
Organization Name:ST LOUIS REHABILITATION PROGRAM INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SEBASTIAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:SILVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-470-6263
Mailing Address - Street 1:4005 NW 114TH AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4374
Mailing Address - Country:US
Mailing Address - Phone:305-470-6263
Mailing Address - Fax:305-470-6540
Practice Address - Street 1:4005 NW 114TH AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4374
Practice Address - Country:US
Practice Address - Phone:305-470-6263
Practice Address - Fax:305-470-6540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684522Medicare ID - Type UnspecifiedCORF