Provider Demographics
NPI:1396183695
Name:TEXAS SPINE AND JOINT REHABILITATION
Entity Type:Organization
Organization Name:TEXAS SPINE AND JOINT REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:214-549-7009
Mailing Address - Street 1:208 W KEARNEY ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3476
Mailing Address - Country:US
Mailing Address - Phone:214-549-7009
Mailing Address - Fax:
Practice Address - Street 1:208 W KEARNEY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3476
Practice Address - Country:US
Practice Address - Phone:214-549-7009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11401111NR0400X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty