Basic Information
| Provider Information | |||||||||
| NPI: | 1093213431 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDCARE PEDIATRIC REHAB CENTER, LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDCARE ABA THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12371 S KIRKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774772836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139959292 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12371 S KIRKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774772836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139959292 | ||||||||
| FaxNumber: | 2812070659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2018 | ||||||||
| LastUpdateDate: | 01/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | KINKADE | ||||||||
| AuthorizedOfficialFirstName: | PAIGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7139959292 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106E00000X | N | 193200000X MULTI-SPECIALTY GROUP | 106S00000X | N | 193200000X MULTI-SPECIALTY GROUP | 225A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Music Therapist | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.