Provider Demographics
NPI:1962440651
Name:JUPITER MEDICAL CENTER PAVILION,INC
Entity Type:Organization
Organization Name:JUPITER MEDICAL CENTER PAVILION,INC
Other - Org Name:JUPITER MEDICAL CENTER PAVILION OUTPATIENT REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:JUSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-262-5485
Mailing Address - Street 1:1230 S OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7205
Mailing Address - Country:US
Mailing Address - Phone:561-262-5485
Mailing Address - Fax:
Practice Address - Street 1:400 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:TEQUESTA
Practice Address - State:FL
Practice Address - Zip Code:33469-2200
Practice Address - Country:US
Practice Address - Phone:561-262-5485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2002-11399261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68-6640Medicare ID - Type UnspecifiedOUTPATIENT REHABILITATION