Provider Demographics
NPI:1043455652
Name:MEDCARE PEDIATRIC REHAB CENTER, LP
Entity Type:Organization
Organization Name:MEDCARE PEDIATRIC REHAB CENTER, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGULATORY COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:713-995-9292
Mailing Address - Street 1:12371 S KIRKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-2836
Mailing Address - Country:US
Mailing Address - Phone:713-995-9292
Mailing Address - Fax:713-995-4402
Practice Address - Street 1:12371 S KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-2836
Practice Address - Country:US
Practice Address - Phone:713-995-9292
Practice Address - Fax:713-995-4402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX454876251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX454876Medicare Oscar/Certification
TX37355Medicare UPIN