Provider Demographics
NPI:1235137506
Name:RENAISSANCE OUTPATIENT REHABILITATION CENTER, LLC.
Entity Type:Organization
Organization Name:RENAISSANCE OUTPATIENT REHABILITATION CENTER, LLC.
Other - Org Name:KIDS KORNER AT RENAISSANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CARRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-682-6900
Mailing Address - Street 1:PO BOX 720157
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-0157
Mailing Address - Country:US
Mailing Address - Phone:956-682-6900
Mailing Address - Fax:956-682-8445
Practice Address - Street 1:910 E 8TH ST STE 7
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-4346
Practice Address - Country:US
Practice Address - Phone:956-702-9882
Practice Address - Fax:956-702-9886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094397902Medicaid
TX0018EXOtherBC/BS PROVIDER ID
TX0018EXOtherBC/BS PROVIDER ID