Provider Demographics
NPI:1235318718
Name:SOURCE ONE REHABILITATION
Entity Type:Organization
Organization Name:SOURCE ONE REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JARROD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:PRES
Authorized Official - Phone:214-577-9191
Mailing Address - Street 1:PO BOX 25006
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-2006
Mailing Address - Country:US
Mailing Address - Phone:972-801-2190
Mailing Address - Fax:972-801-2191
Practice Address - Street 1:5425 W SPRING CREEK PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-4236
Practice Address - Country:US
Practice Address - Phone:972-801-2190
Practice Address - Fax:972-801-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy