Provider Demographics
NPI:1790068690
Name:MUSCULOSKELETAL REHAB OF MOUNT DORA, INC
Entity Type:Organization
Organization Name:MUSCULOSKELETAL REHAB OF MOUNT DORA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAMAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:352-383-0004
Mailing Address - Street 1:807 WAKEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-6219
Mailing Address - Country:US
Mailing Address - Phone:352-383-0004
Mailing Address - Fax:
Practice Address - Street 1:428 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-5663
Practice Address - Country:US
Practice Address - Phone:352-383-0004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA4338305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service