Provider Demographics
NPI:1295762565
Name:EAST TEXAS NEURO REHAB
Entity type:Organization
Organization Name:EAST TEXAS NEURO REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAJAL
Authorized Official - Middle Name:BUENAFLOR
Authorized Official - Last Name:MINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:936-634-4282
Mailing Address - Street 1:609 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3820
Mailing Address - Country:US
Mailing Address - Phone:936-634-4282
Mailing Address - Fax:936-634-4285
Practice Address - Street 1:609 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3820
Practice Address - Country:US
Practice Address - Phone:936-634-4282
Practice Address - Fax:936-634-4285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00934ZMedicare ID - Type UnspecifiedGROUP NUMBER