Provider Demographics
NPI:1477959856
Name:SPACE COAST LYMPHEDEMA CLINIC LLC
Entity type:Organization
Organization Name:SPACE COAST LYMPHEDEMA CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BESSENAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:321-241-6543
Mailing Address - Street 1:7000 SPYGLASS CT.
Mailing Address - Street 2:SUITE 120
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940
Mailing Address - Country:US
Mailing Address - Phone:321-241-6543
Mailing Address - Fax:321-241-6513
Practice Address - Street 1:7000 SPYGLASS CT.
Practice Address - Street 2:SUITE 120
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940
Practice Address - Country:US
Practice Address - Phone:321-241-6543
Practice Address - Fax:321-241-6513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12356225X00000X
FLPT14733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty