Provider Demographics
NPI:1205928561
Name:EAST TEXAS PERFORMANCE REHABILITATION INC
Entity type:Organization
Organization Name:EAST TEXAS PERFORMANCE REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREE
Authorized Official - Middle Name:SIBILLE
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THEREPIST
Authorized Official - Phone:903-247-3244
Mailing Address - Street 1:434 EAST LOOP 281
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605
Mailing Address - Country:US
Mailing Address - Phone:903-247-3422
Mailing Address - Fax:903-247-3424
Practice Address - Street 1:434 EAST LOOP 281
Practice Address - Street 2:SUITE 103
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605
Practice Address - Country:US
Practice Address - Phone:903-247-3422
Practice Address - Fax:903-247-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1033462225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C5981Medicare ID - Type Unspecified