Provider Demographics
NPI:1376739805
Name:NEURO REHAB ASSOCIATES PA
Entity Type:Organization
Organization Name:NEURO REHAB ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-421-9111
Mailing Address - Street 1:PO BOX 92248
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0103
Mailing Address - Country:US
Mailing Address - Phone:817-421-9111
Mailing Address - Fax:817-421-9222
Practice Address - Street 1:680 N CARROLL AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6467
Practice Address - Country:US
Practice Address - Phone:817-421-9111
Practice Address - Fax:817-421-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE51032081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty