Provider Demographics
NPI:1104115112
Name:ATLANTIC COAST MEDICAL REHAB
Entity type:Organization
Organization Name:ATLANTIC COAST MEDICAL REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-888-6095
Mailing Address - Street 1:13171 ATLANTIC BLVD. SUITE #100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225
Mailing Address - Country:US
Mailing Address - Phone:904-888-6095
Mailing Address - Fax:904-280-5238
Practice Address - Street 1:13171 ATLANTIC BLVD. SUITE #100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225
Practice Address - Country:US
Practice Address - Phone:904-888-6095
Practice Address - Fax:904-280-5238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79945174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001KMOtherBLUE CROSS BLUE SHIELD