Provider Demographics
NPI:1093746034
Name:CLASSIC REHABILITATION INC
Entity Type:Organization
Organization Name:CLASSIC REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPT
Authorized Official - Phone:972-263-7042
Mailing Address - Street 1:PO BOX 531513
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75053-1513
Mailing Address - Country:US
Mailing Address - Phone:972-263-7042
Mailing Address - Fax:972-263-7046
Practice Address - Street 1:504 N CARRIER PARKWAY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-5428
Practice Address - Country:US
Practice Address - Phone:972-263-7042
Practice Address - Fax:972-263-7046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1070613261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX456786Medicare Oscar/Certification