Provider Demographics
NPI:1639262264
Name:TEXAS REGIONAL EDEMA LYMPHEDEMA AND WOUND CARE CENTER LLC
Entity Type:Organization
Organization Name:TEXAS REGIONAL EDEMA LYMPHEDEMA AND WOUND CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-257-9770
Mailing Address - Street 1:P. O. BOX 291922
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78029-1922
Mailing Address - Country:US
Mailing Address - Phone:830-257-9770
Mailing Address - Fax:830-257-9760
Practice Address - Street 1:1232 BANDERA HWY.
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028
Practice Address - Country:US
Practice Address - Phone:830-257-9770
Practice Address - Fax:830-257-9760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00402TMedicare ID - Type Unspecified