Provider Demographics
NPI:1295715381
Name:WEST COAST REHAB
Entity type:Organization
Organization Name:WEST COAST REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DULUC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-275-6250
Mailing Address - Street 1:4048 EVANS AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9322
Mailing Address - Country:US
Mailing Address - Phone:239-275-6250
Mailing Address - Fax:239-275-6350
Practice Address - Street 1:4048 EVANS AVE
Practice Address - Street 2:STE 203
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9322
Practice Address - Country:US
Practice Address - Phone:239-275-6250
Practice Address - Fax:239-275-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT5602225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684836Medicare ID - Type Unspecified