Provider Demographics
NPI:1386856177
Name:TEXAS SPINE AND SPORTS REHAB CLINIC LLC
Entity Type:Organization
Organization Name:TEXAS SPINE AND SPORTS REHAB CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:832-647-0761
Mailing Address - Street 1:2925 GULF HWY 3
Mailing Address - Street 2:STE B #347
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573
Mailing Address - Country:US
Mailing Address - Phone:832-647-0761
Mailing Address - Fax:281-282-9711
Practice Address - Street 1:305 FM 517 RD E
Practice Address - Street 2:STE F
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539
Practice Address - Country:US
Practice Address - Phone:832-647-0761
Practice Address - Fax:281-282-9711
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEXAS SPINE AND SPORTS REHAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-04
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10532111N00000X, 111NR0400X, 111NS0005X, 111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
No111NX0100XChiropractic ProvidersChiropractorOccupational HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00X939Medicare PIN