=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346641727
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASCEND REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2014
-----------------------------------------------------
Last Update Date | 10/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1330 E 8TH ST 111
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-4702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-332-4523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 515056
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75251-5056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-617-7463
-----------------------------------------------------
Fax | 972-960-9997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STUART D SMALL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 972-989-6495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0401X
-----------------------------------------------------
Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------