Provider Demographics
NPI:1982039442
Name:KRYSTAL REHABILITATION SERVICES, CORP
Entity Type:Organization
Organization Name:KRYSTAL REHABILITATION SERVICES, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-599-5258
Mailing Address - Street 1:6187 NW 167TH ST STE H13
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4308
Mailing Address - Country:US
Mailing Address - Phone:305-599-5258
Mailing Address - Fax:305-599-5259
Practice Address - Street 1:6187 NW 167TH ST STE H13
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33015-4308
Practice Address - Country:US
Practice Address - Phone:305-599-5258
Practice Address - Fax:305-599-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC9762261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service