Provider Demographics
NPI:1255977583
Name:REHOBOTH MEDICAL CENTER LLC
Entity type:Organization
Organization Name:REHOBOTH MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:IMMANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-506-7412
Mailing Address - Street 1:25231 ROESNER LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-5537
Mailing Address - Country:US
Mailing Address - Phone:281-506-7412
Mailing Address - Fax:281-530-2882
Practice Address - Street 1:25231 ROESNER LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-5537
Practice Address - Country:US
Practice Address - Phone:281-506-7412
Practice Address - Fax:281-530-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty