Provider Demographics
NPI:1487930137
Name:KOOL KIDS CLUB REHABILITATION CENTER
Entity type:Organization
Organization Name:KOOL KIDS CLUB REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:COLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-412-2538
Mailing Address - Street 1:6934 SW 114TH PL APT H
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-1876
Mailing Address - Country:US
Mailing Address - Phone:786-412-2538
Mailing Address - Fax:
Practice Address - Street 1:6934 SW 114TH PL APT H
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-1876
Practice Address - Country:US
Practice Address - Phone:786-412-2538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23932225100000X
FLOT12161225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1871800599OtherINDIVIDUAL NPI
FL1609048230OtherINDIVIDUAL NPI