=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306003983
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS PHYSICAL MEDICINE AND REHABILITATION CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2008
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4915 GUS THOMASSON RD
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-1061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-319-0006
-----------------------------------------------------
Fax | 214-319-9889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4915 GUS THOMASSON RD
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-1061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-319-0006
-----------------------------------------------------
Fax | 214-319-9889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / CEO
-----------------------------------------------------
Name | CHRISTOPHER EDOMWANDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-319-0006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | F005818
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------