Provider Demographics
NPI:1457617425
Name:LAGUNA MADRE REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:LAGUNA MADRE REHABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-644-7368
Mailing Address - Street 1:561 MANCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78737-4543
Mailing Address - Country:US
Mailing Address - Phone:512-644-7368
Mailing Address - Fax:
Practice Address - Street 1:14121 W HWY 290 STE 2B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737-9397
Practice Address - Country:US
Practice Address - Phone:512-644-7368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX297413102OtherCSHCN#
TX297413101Medicaid