1760856595 NPI number — VICTORY REHAB, LLC

Table of content: (NPI 1760856595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760856595 NPI number — VICTORY REHAB, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORY REHAB, LLC
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:
1760856595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17924 SABAL PALM DR
Provider Second Line Business Mailing Address:
STE 3
Provider Business Mailing Address City Name:
PENITAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-581-8060
Provider Business Mailing Address Fax Number:
956-581-8066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7013 S CAGE BLVD STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHARR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78577-8674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-618-2419
Provider Business Practice Location Address Fax Number:
956-618-2114
Provider Enumeration Date:
11/17/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
IZAGUIRRE
Authorized Official First Name:
VERONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
956-618-2419

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  673030001 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 564960001 , 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)