1083747745 NPI number — DEPT OF ASSISTIVE & REHAB SERV - LAREDO FIELD OFFICE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083747745 NPI number — DEPT OF ASSISTIVE & REHAB SERV - LAREDO FIELD OFFICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPT OF ASSISTIVE & REHAB SERV - LAREDO FIELD OFFICE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083747745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12866
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78711-2866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-377-0584
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
313 W VILLAGE BLVD STE 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAREDO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78041-2275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-723-2954
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAYNE
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM MANAGER
Authorized Official Telephone Number:
512-424-4092

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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