Provider Demographics
NPI:1467490136
Name:PREMIER REHAB INC
Entity type:Organization
Organization Name:PREMIER REHAB INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:DIVINCENZO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, CHT
Authorized Official - Phone:386-736-3108
Mailing Address - Street 1:911 N SPRING GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-2560
Mailing Address - Country:US
Mailing Address - Phone:386-736-3108
Mailing Address - Fax:386-736-3643
Practice Address - Street 1:911 N SPRING GARDEN AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720
Practice Address - Country:US
Practice Address - Phone:386-736-3108
Practice Address - Fax:386-736-3643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2674225X00000X
235Z00000X, 261QP2000X
FL261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882094500Medicaid
FL681664996Medicaid
FLR5LOtherBLUE CROSS & BLUE SHIELD
FL681664996Medicaid