Provider Demographics
NPI:1043755457
Name:XTREME MEDICAL REHAB
Entity Type:Organization
Organization Name:XTREME MEDICAL REHAB
Other - Org Name:DFW MEDICAL PAIN & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-656-1615
Mailing Address - Street 1:1710 RUFE SNOW DR
Mailing Address - Street 2:120
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-5745
Mailing Address - Country:US
Mailing Address - Phone:817-656-1615
Mailing Address - Fax:817-428-0573
Practice Address - Street 1:1710 RUFE SNOW DR
Practice Address - Street 2:120
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-5745
Practice Address - Country:US
Practice Address - Phone:817-656-1615
Practice Address - Fax:817-428-0573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6762207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty