Provider Demographics
NPI:1104186634
Name:EAGLE PASS SPINE AND REHAB,LLC
Entity Type:Organization
Organization Name:EAGLE PASS SPINE AND REHAB,LLC
Other - Org Name:SOUTH TEXAS SPINE AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NAKIA
Authorized Official - Middle Name:SHAWNEE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-776-5996
Mailing Address - Street 1:2435 N VETERANS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-6483
Mailing Address - Country:US
Mailing Address - Phone:830-776-5996
Mailing Address - Fax:830-776-5992
Practice Address - Street 1:2435 N VETERANS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-6483
Practice Address - Country:US
Practice Address - Phone:830-776-5996
Practice Address - Fax:830-776-5992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4664111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty