Provider Demographics
NPI:1942283379
Name:EAST LEE COUNTY REBABILITATION CENTER INC
Entity Type:Organization
Organization Name:EAST LEE COUNTY REBABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR & PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLO
Authorized Official - Middle Name:T
Authorized Official - Last Name:PENARANDA
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED PT
Authorized Official - Phone:239-369-0577
Mailing Address - Street 1:1150 LEE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-4805
Mailing Address - Country:US
Mailing Address - Phone:239-369-0577
Mailing Address - Fax:239-369-7540
Practice Address - Street 1:1150 LEE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4805
Practice Address - Country:US
Practice Address - Phone:239-369-0577
Practice Address - Fax:239-369-7540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0004617261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ33OtherBCBS
FL106670Medicare ID - Type Unspecified