Provider Demographics
NPI:1265448054
Name:REAVIS REHAB & WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:REAVIS REHAB & WELLNESS CENTER, INC.
Other - Org Name:REAVIS REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-310-7665
Mailing Address - Street 1:1201 S IH 35
Mailing Address - Street 2:STE 105
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-6615
Mailing Address - Country:US
Mailing Address - Phone:512-310-7665
Mailing Address - Fax:512-310-9228
Practice Address - Street 1:1201 S IH 35
Practice Address - Street 2:STE 105
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-6615
Practice Address - Country:US
Practice Address - Phone:512-310-7665
Practice Address - Fax:512-310-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX611620000261QP2000X, 261QR0401X
TX261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0031DGOtherBLUE CROSS BLUE SHIELD TX
TX094474602Medicaid
TX456890Medicare Oscar/Certification