Provider Demographics
NPI:1467503151
Name:LIFE SPAN REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:LIFE SPAN REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-601-2274
Mailing Address - Street 1:1200 E BUSINESS 83
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-4758
Mailing Address - Country:US
Mailing Address - Phone:956-601-2274
Mailing Address - Fax:956-601-2275
Practice Address - Street 1:1200 E BUSINESS 83
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-4758
Practice Address - Country:US
Practice Address - Phone:956-782-4647
Practice Address - Fax:956-782-5081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0019MEOtherBCBS TX
TX212023001Medicaid
TX137692OtherCHIPS
TX137692OtherCHIPS