Provider Demographics
NPI:1386741189
Name:LIFE SPAN REHAB CORP
Entity type:Organization
Organization Name:LIFE SPAN REHAB CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & ADMINISTRATOR LIFE SPAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:LIZ
Authorized Official - Last Name:CAMARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-871-5882
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-0161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4710 N HABANA AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614
Practice Address - Country:US
Practice Address - Phone:813-871-5882
Practice Address - Fax:813-871-5884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC3748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4280Medicare ID - Type Unspecified