Healthcare Provider Details

I. General information

NPI: 1154567568
Provider Name (Legal Business Name): SAFARI KIDS REHABILITATION CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 CHIHUAHUA ST SUITE# 3
LAREDO TX
78043-3658
US

IV. Provider business mailing address

2108 CHIHUAHUA ST SUITE#2
LAREDO TX
78043-3657
US

V. Phone/Fax

Practice location:
  • Phone: 956-568-4675
  • Fax: 956-568-4671
Mailing address:
  • Phone: 956-568-4675
  • Fax: 956-568-4671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number111552
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number100691
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number676667
License Number StateTX

VIII. Authorized Official

Name: MRS. ESMERALDA E. GONZALEZ
Title or Position: CO-OWNER,SPEECH LANGUAGE PATHOLOGIS
Credential: M.A., CCC-SLP
Phone: 956-568-4675