1285703397 NPI number — CUSTOM REHAB OF NORTH TEXAS, INC.

Table of content: (NPI 1285703397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285703397 NPI number — CUSTOM REHAB OF NORTH TEXAS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM REHAB OF NORTH TEXAS, 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:
1285703397
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:
810 S SAINT PAUL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75201-6216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-744-3606
Provider Business Mailing Address Fax Number:
214-744-3609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 S SAINT PAUL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75201-6216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-744-3606
Provider Business Practice Location Address Fax Number:
214-744-3609
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHIELDS
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
214-744-3606

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0085543 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 515568 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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