Basic Information
| Provider Information | |||||||||
| NPI: | 1699804732 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST TEXAS REHABILITATION CENTER | ||||||||
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| OtherOrganizationName: | REHAB SPORT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 HARTFORD ST | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796054603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3257933400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2074 ANTILLEY RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796065209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3254371219 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 10/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHILDS | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3257933400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 137920805 | 05 | TX | MEDICAID |