Provider Demographics
NPI:1306003983
Name:TEXAS PHYSICAL MEDICINE AND REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:TEXAS PHYSICAL MEDICINE AND REHABILITATION CENTER, INC.
Other - Org Name:THE HEALTH CENTER AT LAPRADA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:EDOMWANDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-319-0006
Mailing Address - Street 1:4915 GUS THOMASSON RD
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-1061
Mailing Address - Country:US
Mailing Address - Phone:214-319-0006
Mailing Address - Fax:214-319-9889
Practice Address - Street 1:4915 GUS THOMASSON RD
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-1061
Practice Address - Country:US
Practice Address - Phone:214-319-0006
Practice Address - Fax:214-319-9889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF005818261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service