Basic Information
| Provider Information | |||||||||
| NPI: | 1144277674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDCARE PEDIATRIC REHAB CENTER, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12371 S KIRKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774772836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137735100 | ||||||||
| FaxNumber: | 7137735151 | ||||||||
| Practice Location | |||||||||
| Address1: | 12371 S KIRKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | STAFFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139959292 | ||||||||
| FaxNumber: | 2812070659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2006 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | KINKADE | ||||||||
| AuthorizedOfficialFirstName: | PAIGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO - ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7137735100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDCARE PEDIATRIC GROUP, LP | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | 45-4876 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
ID Information
| ID | Type | State | Issuer | Description | 1801326-01 | 05 | TX | MEDICAID |