Provider Demographics
NPI:1477812857
Name:LITTLE STAR REHAB
Entity Type:Organization
Organization Name:LITTLE STAR REHAB
Other - Org Name:LITTLE STARS REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-822-9195
Mailing Address - Street 1:4525 ALTAMESA BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133
Mailing Address - Country:US
Mailing Address - Phone:817-822-9195
Mailing Address - Fax:
Practice Address - Street 1:4525 ALTAMESA BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133
Practice Address - Country:US
Practice Address - Phone:817-822-9195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No305S00000XManaged Care OrganizationsPoint of Service