Healthcare Provider Details

I. General information

NPI: 1811087166
Provider Name (Legal Business Name): PROVIDENCE REHABILITATION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 08/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 E GRIFFIN PKWY SUITE B
MISSION TX
78572-3101
US

IV. Provider business mailing address

1609 E GRIFFIN PKWY SUITE B
MISSION TX
78572-3101
US

V. Phone/Fax

Practice location:
  • Phone: 956-424-1089
  • Fax: 956-424-1090
Mailing address:
  • Phone: 956-424-1089
  • Fax: 956-424-1090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number657030000
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number657030000
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: RUBY BOCANEGRA
Title or Position: PRESIDENT
Credential:
Phone: 956-424-1089