Provider Demographics
NPI:1871734541
Name:ROCK STAR REP INC
Entity type:Organization
Organization Name:ROCK STAR REP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:MONTY
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-513-0349
Mailing Address - Street 1:5305 OAKWAY DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-8584
Mailing Address - Country:US
Mailing Address - Phone:863-513-0349
Mailing Address - Fax:863-248-0453
Practice Address - Street 1:10065 US HIGHWAY 98 W
Practice Address - Street 2:STE B 101
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-4924
Practice Address - Country:US
Practice Address - Phone:850-837-8005
Practice Address - Fax:850-837-4352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-10
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center