Basic Information
| Provider Information | |||||||||
| NPI: | 1366704355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC REHABILITATION OF TEXAS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3195 CALDER ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098334115 | ||||||||
| FaxNumber: | 4098331626 | ||||||||
| Practice Location | |||||||||
| Address1: | 3195 CALDER ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098334115 | ||||||||
| FaxNumber: | 4098331626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 06/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | KENT | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4098334115 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BSPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 1012458 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.