1164416988 NPI number — NACOGDOCHES REHABILITATION GROUP, INC

Table of content: (NPI 1164416988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164416988 NPI number — NACOGDOCHES REHABILITATION GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NACOGDOCHES REHABILITATION GROUP, INC
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:
1164416988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3205 N UNIVERSITY DR
Provider Second Line Business Mailing Address:
SUITE M
Provider Business Mailing Address City Name:
NACOGDOCHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75965-2683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-552-7044
Provider Business Mailing Address Fax Number:
936-552-7050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3205 N UNIVERSITY DR
Provider Second Line Business Practice Location Address:
SUITE M
Provider Business Practice Location Address City Name:
NACOGDOCHES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75965-2683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-552-7044
Provider Business Practice Location Address Fax Number:
936-552-7050
Provider Enumeration Date:
09/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CUEVAS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
936-552-7044

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  1101582 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2000X , with the licence number: 1108322 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0049HV . This is a "BCBSTX PROVIDOR #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5856810001 . This is a "MEDICARE SUPPLIER / DME#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00016007/DA2661 . This is a "MEDICARE RAILROAD ID/GROU" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5856810001 . This is a "DME" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5856810001 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 170788701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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