Provider Demographics
NPI:1609067859
Name:SPECIALIZED REHABILITATION LLC
Entity Type:Organization
Organization Name:SPECIALIZED REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:B
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, MBA
Authorized Official - Phone:956-722-0200
Mailing Address - Street 1:PO BOX 451261
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-0031
Mailing Address - Country:US
Mailing Address - Phone:956-722-0200
Mailing Address - Fax:956-722-0611
Practice Address - Street 1:4151 JAIME ZAPATA MEMORIAL HWY.
Practice Address - Street 2:SUITE 208
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78043-4782
Practice Address - Country:US
Practice Address - Phone:956-722-0200
Practice Address - Fax:956-722-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119580204Medicaid
TX184376501Medicaid