Provider Demographics
NPI:1366704355
Name:PEDIATRIC REHABILITATION OF TEXAS, INC.
Entity type:Organization
Organization Name:PEDIATRIC REHABILITATION OF TEXAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:BSPT
Authorized Official - Phone:409-833-4115
Mailing Address - Street 1:3195 CALDER ST
Mailing Address - Street 2:STE 201
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1425
Mailing Address - Country:US
Mailing Address - Phone:409-833-4115
Mailing Address - Fax:409-833-1626
Practice Address - Street 1:3195 CALDER ST
Practice Address - Street 2:STE 201
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1425
Practice Address - Country:US
Practice Address - Phone:409-833-4115
Practice Address - Fax:409-833-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1012458261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy