Provider Demographics
NPI:1952346264
Name:LAKE JACKSON REHABILITATION AND WELLNESS CENTER
Entity Type:Organization
Organization Name:LAKE JACKSON REHABILITATION AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-802-1441
Mailing Address - Street 1:242 FLAMINGO ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4611
Mailing Address - Country:US
Mailing Address - Phone:281-802-1441
Mailing Address - Fax:713-634-2697
Practice Address - Street 1:117 CIRCLE WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5233
Practice Address - Country:US
Practice Address - Phone:979-480-9400
Practice Address - Fax:979-480-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX650330002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00377VMedicare ID - Type Unspecified