Provider Demographics
NPI:1770855934
Name:LAVIE REHAB
Entity Type:Organization
Organization Name:LAVIE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:850-832-8071
Mailing Address - Street 1:10210 HIGHLAND MANOR DR
Mailing Address - Street 2:STE 270
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-9151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:636 TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404
Practice Address - Country:US
Practice Address - Phone:850-871-6363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11464314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility