Provider Demographics
NPI:1720095367
Name:KINGSVILLE HOME REHAB SERVICES
Entity Type:Organization
Organization Name:KINGSVILLE HOME REHAB SERVICES
Other - Org Name:SYNERGY PHYSICAL THERAPY & SPORTS MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:SORENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:361-225-2525
Mailing Address - Street 1:12417 N MOPAC EXPWY
Mailing Address - Street 2:STE 575B
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758
Mailing Address - Country:US
Mailing Address - Phone:361-225-2525
Mailing Address - Fax:361-225-2530
Practice Address - Street 1:3633 S STAPLES ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2438
Practice Address - Country:US
Practice Address - Phone:361-225-2525
Practice Address - Fax:361-225-2530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1140622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y920Medicare PIN