Basic Information
| Provider Information | |||||||||
| NPI: | 1104958701 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERMIAN BASIN REHABILITATION CENTER FOR CRIPPLED CHILDREN AND ADULTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 N ALLEGHANEY AVE | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797614408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323328244 | ||||||||
| FaxNumber: | 4325807428 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 N ALLEGHANEY AVE | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797614408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323328244 | ||||||||
| FaxNumber: | 4325807428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 12/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | KUEHLER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | WADE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4323328244 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
ID Information
| ID | Type | State | Issuer | Description | 051CT | 01 | TX | BCBS GROUP NUMBER | OTHER | 5589378 | 01 | TX | AETNA BILLING NUM | OTHER | 531269 | 01 | TX | BCBS HEARING AID ID NUM | OTHER | 094460501 | 05 | TX | MEDICAID |