Provider Demographics
NPI:1972654663
Name:TEMPLE MEMORIAL PEDIATRIC CENTER INC.
Entity Type:Organization
Organization Name:TEMPLE MEMORIAL PEDIATRIC CENTER INC.
Other - Org Name:TEMPLE MEMORIAL REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:VARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-794-2705
Mailing Address - Street 1:1710 MOORES LN
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1858
Mailing Address - Country:US
Mailing Address - Phone:903-794-2705
Mailing Address - Fax:903-793-1203
Practice Address - Street 1:1710 MOORES LN
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1858
Practice Address - Country:US
Practice Address - Phone:903-794-2705
Practice Address - Fax:903-793-1203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
TX009425261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX021289601Medicaid
TX8P097OtherARKANSAS BCBS
AR116506742Medicaid
TX00T7468OtherBCBS OF TEXAS
TX021289601Medicaid