1013036508 NPI number — BRELAND HEALTH & REHAB GROUP INC.

Table of content: (NPI 1013036508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013036508 NPI number — BRELAND HEALTH & REHAB GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRELAND HEALTH & REHAB 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:
1013036508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 S RED RIVER EXPY
Provider Second Line Business Mailing Address:
STE E
Provider Business Mailing Address City Name:
BURKBURNETT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76354-3752
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-569-3630
Provider Business Mailing Address Fax Number:
940-569-3752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 NW HOMESTEAD DR
Provider Second Line Business Practice Location Address:
STE E
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505-5243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-353-6300
Provider Business Practice Location Address Fax Number:
580-353-6319
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRELAND
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
940-569-3630

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  OK2429 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 640900000 , 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)

  • Identifier: 1008356996A . This is a "CRAIG MCBRIDE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 376591 . This is a "OKLAHOMA MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100835690A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 167449101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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