Provider Demographics
NPI:1811120702
Name:SHANON RIVER HOLDINGS INC
Entity type:Organization
Organization Name:SHANON RIVER HOLDINGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:954-600-9836
Mailing Address - Street 1:137 BIRCHMONT DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-8851
Mailing Address - Country:US
Mailing Address - Phone:954-600-9836
Mailing Address - Fax:386-775-9835
Practice Address - Street 1:137 BIRCHMONT DR
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-8851
Practice Address - Country:US
Practice Address - Phone:954-600-9836
Practice Address - Fax:386-775-9835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT6160261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy