Provider Demographics
NPI:1831294412
Name:AQUATIC HEALTH AND REHABILITATION SERVICES INC
Entity Type:Organization
Organization Name:AQUATIC HEALTH AND REHABILITATION SERVICES INC
Other - Org Name:AQUATIC HEALTH AND REHAB
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TEREASA
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:PT,MSHA
Authorized Official - Phone:321-453-8484
Mailing Address - Street 1:PO BOX 541210
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32954-1210
Mailing Address - Country:US
Mailing Address - Phone:321-453-8484
Mailing Address - Fax:321-453-8448
Practice Address - Street 1:595 N COURTENAY PKWY
Practice Address - Street 2:#203
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4851
Practice Address - Country:US
Practice Address - Phone:321-453-8484
Practice Address - Fax:321-453-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888029800Medicaid
FL9725170OtherGHI
FL7742686OtherAETNA
FLY904DOtherBCBS
GAP00060639OtherRAILROAD MEDICARE
FL888029800Medicaid
FL=========002OtherCHAMPUS/TRICARE
FL888029800Medicaid