Healthcare Provider Details

I. General information

NPI: 1417438458
Provider Name (Legal Business Name): PROHEALTH REHAB & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 LEGACY DR STE 326
FRISCO TX
75034-0811
US

IV. Provider business mailing address

715FM 1959RD 1009
HOUSTON TX
77034
US

V. Phone/Fax

Practice location:
  • Phone: 480-646-6004
  • Fax:
Mailing address:
  • Phone: 480-646-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number StateTX

VIII. Authorized Official

Name: MARC A RESASCO
Title or Position: PRESIDENT
Credential:
Phone: 480-646-6004