Provider Demographics
NPI:1881676393
Name:BRAZOS VALLEY REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:BRAZOS VALLEY REHABILITATION CENTER INC
Other - Org Name:BRAZOS VALLEY REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALINA
Authorized Official - Middle Name:MIHAELA
Authorized Official - Last Name:FIFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-776-2872
Mailing Address - Street 1:1318 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5215
Mailing Address - Country:US
Mailing Address - Phone:979-776-2872
Mailing Address - Fax:979-776-1456
Practice Address - Street 1:1318 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-5215
Practice Address - Country:US
Practice Address - Phone:979-776-2872
Practice Address - Fax:979-776-1456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60458005225100000X
TX508480005225X00000X
TX235Z00000X
261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No225100000XRespiratory, 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
TX094393801Medicaid
TX094393801Medicaid