Basic Information
| Provider Information | |||||||||
| NPI: | 1346399557 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECTRUM THERAPEUTIC ENTERPRISES, LLP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BUILDING BLOCKS REHABILITATION & AUTISM CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5013 S MCCOLL RD | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785398080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566868485 | ||||||||
| FaxNumber: | 9566868489 | ||||||||
| Practice Location | |||||||||
| Address1: | 5013 S MCCOLL RD | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785398080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566868485 | ||||||||
| FaxNumber: | 9566868489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 02/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | PALOMIN | ||||||||
| AuthorizedOfficialFirstName: | OMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9566874559 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 225XP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 261QR0401X | 552280000(OT)6549100 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
ID Information
| ID | Type | State | Issuer | Description | 167245302 | 05 | TX | MEDICAID |