MEDICARE: INTERVENTIONAL REHABILITATION CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	1061	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1061	OTHER	FL	LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205839487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTIONAL REHABILITATION CENTER, LLC

Provider Business Mailing Address
First Line	:	9709 LAKESIDE BLVD STE 350
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77381-1216
Country	:	US
Telephone Number	:	713-489-2198
Fax Number	:	713-489-2978

Provider Business Practice Location Address
First Line	:	1549 AIRPORT BLVD
Second Line	:	STE 420
City	:	PENSACOLA
State	:	FL
Zip	:	32504-8633
Country	:	US
Telephone Number	:	850-484-8800
Fax Number	:	850-484-6020

Authorized Official
Title or Position	:	CEO
Name	:	DEVIN LARSEN
Credential	:
Telephone Number	:	208-340-1840

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	03/16/2026

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