Basic Information
| Provider Information | |||||||||
| NPI: | 1558554402 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOUSTON REHABILITATION SPECIALIST, P.A. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 520 | ||||||||
| Address2: | |||||||||
| City: | KATY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774920520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815795532 | ||||||||
| FaxNumber: | 2815795601 | ||||||||
| Practice Location | |||||||||
| Address1: | 21720 KINGSLAND BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | KATY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774502550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815795532 | ||||||||
| FaxNumber: | 2812777101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 01/04/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANDONGEN | ||||||||
| AuthorizedOfficialFirstName: | DANIQUE | ||||||||
| AuthorizedOfficialMiddleName: | LYSANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/OPERATOR | ||||||||
| AuthorizedOfficialTelephone: | 2815795532 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | M6929 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.