Provider Demographics
NPI:1700930633
Name:CUSTOM REHAB OF SOUTH TEXAS, INC.
Entity Type:Organization
Organization Name:CUSTOM REHAB OF SOUTH TEXAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-793-7570
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:NEEDVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77461-0467
Mailing Address - Country:US
Mailing Address - Phone:979-793-7570
Mailing Address - Fax:979-793-5540
Practice Address - Street 1:12907 HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:NEEDVILLE
Practice Address - State:TX
Practice Address - Zip Code:77461
Practice Address - Country:US
Practice Address - Phone:979-793-7570
Practice Address - Fax:979-793-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10023796OtherAMERIGROUP PROVIDER #
TX519066OtherBLUE CROSS BLUE SHIELD
TX010008301Medicaid
TX011390401Medicaid
TX011390401Medicaid