Provider Demographics
NPI:1417225822
Name:TS CARLSON PEDIATRIC REHAB LP
Entity Type:Organization
Organization Name:TS CARLSON PEDIATRIC REHAB LP
Other - Org Name:HEALTHSTAR PEDIATRIC REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STACI
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:915-779-7827
Mailing Address - Street 1:6800 GATEWAY BLVD E
Mailing Address - Street 2:BLDG 4A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-1040
Mailing Address - Country:US
Mailing Address - Phone:915-779-7827
Mailing Address - Fax:915-779-7829
Practice Address - Street 1:6800 GATEWAY BLVD E
Practice Address - Street 2:BLDG 4A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915-1040
Practice Address - Country:US
Practice Address - Phone:915-779-7827
Practice Address - Fax:915-779-7829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX295233501Medicaid