Provider Demographics
NPI:1356772925
Name:CENTER FOR PAIN REHABILITATION, PA
Entity type:Organization
Organization Name:CENTER FOR PAIN REHABILITATION, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:713-771-2225
Mailing Address - Street 1:8200 WEDNESBURY LN STE 210
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-2931
Mailing Address - Country:US
Mailing Address - Phone:713-771-2225
Mailing Address - Fax:713-771-1876
Practice Address - Street 1:8200 WEDNESBURY LN STE 210
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-2931
Practice Address - Country:US
Practice Address - Phone:713-771-2225
Practice Address - Fax:713-771-1876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ICH HEALTHCARE, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62953101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty