Provider Demographics
NPI:1548809940
Name:KRATOS REHABILITATION LLC
Entity type:Organization
Organization Name:KRATOS REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER/OT
Authorized Official - Prefix:
Authorized Official - First Name:LIDA
Authorized Official - Middle Name:EUDALY
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:908-906-0978
Mailing Address - Street 1:329 VINE ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-1817
Mailing Address - Country:US
Mailing Address - Phone:908-906-0978
Mailing Address - Fax:
Practice Address - Street 1:171 ELMORA AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-1169
Practice Address - Country:US
Practice Address - Phone:908-906-0978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR00354400OtherNJ STATE LICENSE