=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750945853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORES PEDIATRIC REHAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2019
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3012 E MAIN AVE STE H
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78573-0908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-638-6162
-----------------------------------------------------
Fax | 956-435-0146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3012 E. MAIN AVE SUITE H & I
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78573-7995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-638-6162
-----------------------------------------------------
Fax | 956-435-0146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JANELLY FLORES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-638-6162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------