=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437547320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL MEDICINE & REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2014
-----------------------------------------------------
Last Update Date | 06/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25404 HIGHWAY 59 SUITE 102
-----------------------------------------------------
City | PORTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77365-5295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-354-4000
-----------------------------------------------------
Fax | 281-354-8128
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25404 HIGHWAY 59 SUITE 102
-----------------------------------------------------
City | PORTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77365-5295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-354-4000
-----------------------------------------------------
Fax | 281-354-8128
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER LANGELAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-354-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 4256
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------