=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962646315
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BULVERDE REHABILITATION & WELLNESS CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2009
-----------------------------------------------------
Last Update Date | 04/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20475 HWY 46W #150
-----------------------------------------------------
City | SPRING BRANCH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78070-6180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-980-4055
-----------------------------------------------------
Fax | 830-438-4085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20475 HWY 46W #150
-----------------------------------------------------
City | SPRING BRANCH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78070-6180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-980-4055
-----------------------------------------------------
Fax | 830-438-4085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DARLENE MCGILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 830-980-4055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 633230000
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------