Provider Demographics
NPI:1376670265
Name:FEDERAL ROAD REHAB & DIAGNOSTIC INC
Entity Type:Organization
Organization Name:FEDERAL ROAD REHAB & DIAGNOSTIC INC
Other - Org Name:NORTHSHORE AQUATHERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOWALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:713-451-1400
Mailing Address - Street 1:12655 WOODFOREST BLVD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-3564
Mailing Address - Country:US
Mailing Address - Phone:713-455-2535
Mailing Address - Fax:713-451-1411
Practice Address - Street 1:12655 WOODFOREST BLVD STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-3575
Practice Address - Country:US
Practice Address - Phone:713-455-2535
Practice Address - Fax:713-451-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2889111NX0800X
TX1013647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328188800OtherDOL
TX0091KKOtherBC/ BS GRP #
TX045155001Medicaid
TXCS4064OtherMEDICARE RAILROAD
TX350017778OtherRAILROAD MEDICARE
TXR69370Medicare UPIN
TX350017778OtherRAILROAD MEDICARE