Provider Demographics
NPI:1316915184
Name:RENEW THERAPY CENTER OF PALM BAY, LLC
Entity type:Organization
Organization Name:RENEW THERAPY CENTER OF PALM BAY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:OCASIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-768-9776
Mailing Address - Street 1:490 CENTRE LAKE DR NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1189
Mailing Address - Country:US
Mailing Address - Phone:321-768-9776
Mailing Address - Fax:321-768-9739
Practice Address - Street 1:490 CENTRE LAKE DR NE
Practice Address - Street 2:SUITE 100
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1189
Practice Address - Country:US
Practice Address - Phone:321-768-9776
Practice Address - Fax:321-768-9739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684851Medicare ID - Type UnspecifiedCORF