Basic Information
Provider Information | |||||||||
NPI: | 1427103019 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RGV REHAB NORTH LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NISKERS-RGV REHAB-HARLINGEN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 S. JACKSON RD, STE 2 | ||||||||
Address2: |   | ||||||||
City: | MCALLEN | ||||||||
State: | TX | ||||||||
PostalCode: | 78503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9566304400 | ||||||||
FaxNumber: | 9566304447 | ||||||||
Practice Location | |||||||||
Address1: | 702 N. ED CAREY DRIVE | ||||||||
Address2: |   | ||||||||
City: | HARLINGEN | ||||||||
State: | TX | ||||||||
PostalCode: | 78550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9564401155 | ||||||||
FaxNumber: | 9564400913 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2007 | ||||||||
LastUpdateDate: | 01/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GONZALEZ | ||||||||
AuthorizedOfficialFirstName: | JORGE | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CFO/OWNER | ||||||||
AuthorizedOfficialTelephone: | 9566304400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X |   | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
ID Information
ID | Type | State | Issuer | Description | 154838001 | 05 | TX |   | MEDICAID |