=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548205743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGLETON REHABILITATION AND WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2006
-----------------------------------------------------
Last Update Date | 06/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2327 W HIGHWAY 35
-----------------------------------------------------
City | ANGLETON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77515-7455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-848-1886
-----------------------------------------------------
Fax | 979-848-1376
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 41027
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77241-1027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-864-3821
-----------------------------------------------------
Fax | 979-848-8563
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | DANIEL DOMINGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 979-864-3821
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 650330000
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------