Provider Demographics
NPI:1295841070
Name:ADVANCED WELLNESS AND REHAB CENTER
Entity Type:Organization
Organization Name:ADVANCED WELLNESS AND REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CORINNA
Authorized Official - Middle Name:CARLA
Authorized Official - Last Name:JUMAO-AS
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:972-392-7008
Mailing Address - Street 1:6029 BELT LINE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-9137
Mailing Address - Country:US
Mailing Address - Phone:972-392-7008
Mailing Address - Fax:972-392-1171
Practice Address - Street 1:6029 BELT LINE RD STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-9137
Practice Address - Country:US
Practice Address - Phone:972-392-7008
Practice Address - Fax:972-392-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC4635111N00000X, 171100000X, 225100000X
TX111489225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0034KDOtherBLUE CROSS BLUE SHIELD GR
TX8T4335OtherBLUECROSS BLUE SHIELD
TX8J3270OtherBLUE CROSS BLUE SHIELD
TXU14166Medicare UPIN
TX0034KDOtherBLUE CROSS BLUE SHIELD GR