Provider Demographics
NPI:1194082909
Name:PREMIER ATHLETIC REHAB CENTER LLC
Entity type:Organization
Organization Name:PREMIER ATHLETIC REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ALEJANDRO
Authorized Official - Middle Name:G
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:305-282-7252
Mailing Address - Street 1:PO BOX 450844
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33245-0844
Mailing Address - Country:US
Mailing Address - Phone:305-396-9002
Mailing Address - Fax:305-390-3003
Practice Address - Street 1:3121 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-6816
Practice Address - Country:US
Practice Address - Phone:305-396-9002
Practice Address - Fax:305-390-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25977261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY07QROtherBCBS
FL2801168OtherCIGNA