1104958701 NPI number — PERMIAN BASIN REHABILITATION CENTER FOR CRIPPLED CHILDREN AND ADULTS

Table of content: (NPI 1104958701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104958701 NPI number — PERMIAN BASIN REHABILITATION CENTER FOR CRIPPLED CHILDREN AND ADULTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERMIAN BASIN REHABILITATION CENTER FOR CRIPPLED CHILDREN AND ADULTS
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:
1104958701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 N ALLEGHANEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79761-4408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-332-8244
Provider Business Mailing Address Fax Number:
432-580-7428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 N ALLEGHANEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-4408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-332-8244
Provider Business Practice Location Address Fax Number:
432-580-7428
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ORTEGA
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
RUBY
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
432-332-8244

Provider Taxonomy Codes

  • Taxonomy code: 261QR0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 051CT . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 531269 . This is a "BCBS HEARING AID ID NUM" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5589378 . This is a "AETNA BILLING NUM" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 094460501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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