Healthcare Provider Details

I. General information

NPI: 1003045741
Provider Name (Legal Business Name): PEDERSON-MARTINEZ PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W. MILE 3 RD STE A-103
PALMHURST TX
78573
US

IV. Provider business mailing address

123 W. MILE 3 RD STE A-103
PALMHURST TX
78573
US

V. Phone/Fax

Practice location:
  • Phone: 956-585-9889
  • Fax: 956-585-9896
Mailing address:
  • Phone: 956-585-9889
  • Fax: 956-585-9896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MR. SHANE MARLON PEDERSON
Title or Position: PRESIDENT/PHYSICAL THERAPIST
Credential:
Phone: 956-585-9889