Provider Demographics
NPI:1396950341
Name:PROVIDENTIAL HEALTH & REHAB, INC.
Entity type:Organization
Organization Name:PROVIDENTIAL HEALTH & REHAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAXIMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VICTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-856-8584
Mailing Address - Street 1:5205 S ORANGE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-3067
Mailing Address - Country:US
Mailing Address - Phone:407-856-8584
Mailing Address - Fax:
Practice Address - Street 1:5205 S ORANGE AVE STE 102
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-3067
Practice Address - Country:US
Practice Address - Phone:407-856-8584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6145273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit