Provider Demographics
NPI:1972038917
Name:PA MEDICAL REHAB CENTER LLC
Entity Type:Organization
Organization Name:PA MEDICAL REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ORELVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-582-1780
Mailing Address - Street 1:2900 LOUISIANA BLVD NE SUITE H
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-582-1780
Mailing Address - Fax:
Practice Address - Street 1:2900 LOUISIANA BLVD NE STE H
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3565
Practice Address - Country:US
Practice Address - Phone:505-582-1780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service