Provider Demographics
NPI:1699727156
Name:FUNCTIONAL REHAB OF EAST FT. MYERS, INC.
Entity type:Organization
Organization Name:FUNCTIONAL REHAB OF EAST FT. MYERS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:DIAZ
Authorized Official - Last Name:SAUSA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MA, DPT
Authorized Official - Phone:239-850-1891
Mailing Address - Street 1:PO BOX 2565
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2565
Mailing Address - Country:US
Mailing Address - Phone:239-690-3100
Mailing Address - Fax:239-693-3200
Practice Address - Street 1:14630 PALM BEACH BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-2333
Practice Address - Country:US
Practice Address - Phone:239-690-3100
Practice Address - Fax:239-693-3200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 7037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7933Medicare ID - Type UnspecifiedOUT-PATIENT REHAB CLINIC
FLK5473Medicare ID - Type UnspecifiedOUT-PATIENT REHAB CLINIC