Provider Demographics
NPI:1740578251
Name:ALLEGIANT REHAB
Entity Type:Organization
Organization Name:ALLEGIANT REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OCCUPATIONAL THERAPY ASST
Authorized Official - Prefix:
Authorized Official - First Name:DER JUANA
Authorized Official - Middle Name:SHARMEN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:313-559-5535
Mailing Address - Street 1:753 MAIN STREET STREET
Mailing Address - Street 2:STE C
Mailing Address - City:ALAMO
Mailing Address - State:TX
Mailing Address - Zip Code:78516
Mailing Address - Country:US
Mailing Address - Phone:313-559-5535
Mailing Address - Fax:
Practice Address - Street 1:753 MAIN STREET STREET
Practice Address - Street 2:STE C
Practice Address - City:ALAMO
Practice Address - State:TX
Practice Address - Zip Code:78516
Practice Address - Country:US
Practice Address - Phone:313-559-5535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210898261QR0400X
MI5202007235261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation