Provider Demographics
NPI:1245533959
Name:SHINE REHAB INC
Entity type:Organization
Organization Name:SHINE REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROWENA
Authorized Official - Middle Name:CABADING
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:941-625-1252
Mailing Address - Street 1:2301 TAMIAMI TRAIL
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952
Mailing Address - Country:US
Mailing Address - Phone:941-625-1252
Mailing Address - Fax:941-625-0616
Practice Address - Street 1:2301 TAMIAMI TRL
Practice Address - Street 2:SUITE C
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-3907
Practice Address - Country:US
Practice Address - Phone:941-625-1252
Practice Address - Fax:941-625-0616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10614261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1568677938Medicare UPIN