Provider Demographics
NPI:1972633600
Name:PROFESSIONAL MEDICAL PHYSICAL HEALTH LLC
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL PHYSICAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-805-5447
Mailing Address - Street 1:489 HIALEAH DR
Mailing Address - Street 2:UNIT 6
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-5320
Mailing Address - Country:US
Mailing Address - Phone:305-805-5447
Mailing Address - Fax:305-805-5447
Practice Address - Street 1:489 HIALEAH DR
Practice Address - Street 2:UNIT 6
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-5320
Practice Address - Country:US
Practice Address - Phone:305-805-5447
Practice Address - Fax:305-805-5447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686888Medicare Oscar/Certification