Provider Demographics
NPI:1114066941
Name:PROFESSIONAL REHAB OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:PROFESSIONAL REHAB OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:281-363-1005
Mailing Address - Street 1:318 BRIAR ROCK RD
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3528
Mailing Address - Country:US
Mailing Address - Phone:281-363-1005
Mailing Address - Fax:281-292-2092
Practice Address - Street 1:318 BRIAR ROCK RD
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3528
Practice Address - Country:US
Practice Address - Phone:281-363-1005
Practice Address - Fax:281-292-2092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX04566890Medicaid
TX456689Medicare ID - Type Unspecified