MEDICARE: ROCKPORT THERAPY CLINIC, 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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)

General Provider Information

NPI Number	:	1487169843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKPORT THERAPY CLINIC, LLC

Provider Business Mailing Address
First Line	:	1004 E MAIN ST STE D
Second Line	:
City	:	ROCKPORT
State	:	TX
Zip	:	78382-2610
Country	:	US
Telephone Number	:	361-389-8253
Fax Number	:

Provider Business Practice Location Address
First Line	:	1004 E MAIN ST STE D
Second Line	:
City	:	ROCKPORT
State	:	TX
Zip	:	78382-2610
Country	:	US
Telephone Number	:	361-389-8253
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED AGENT
Name	:	LINCOLN WAYNE DAVIS
Credential	:	PTA
Telephone Number	:	361-727-6141

Provider Enumeration Date	:	12/07/2017
Last Update Date	:	01/31/2018

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