=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043755457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | XTREME MEDICAL REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2016
-----------------------------------------------------
Last Update Date | 12/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1710 RUFE SNOW DR 120
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-5745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-656-1615
-----------------------------------------------------
Fax | 817-428-0573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 RUFE SNOW DR 120
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-5745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-656-1615
-----------------------------------------------------
Fax | 817-428-0573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JASON WANDER
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 817-656-1615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | N6762
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | N6762
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------