=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679688535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPROCK SPORTS REHABILITATION CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 01/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4712 67TH ST SUITE A
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79414-5004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-795-2673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4712 67TH ST SUITE A
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79414-5004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-795-2673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGEMENT CONSULTING
-----------------------------------------------------
Name | MR. BRYAN WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-771-1166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0401X
-----------------------------------------------------
Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
-----------------------------------------------------
License Number | 1136992
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------