MEDICARE: MOTHERLAND, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)		TX

General Provider Information

NPI Number	:	1134180201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOTHERLAND, INC.

Provider Business Mailing Address
First Line	:	4040 YALE ST.
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-5928
Country	:	US
Telephone Number	:	713-290-0001
Fax Number	:	713-290-0023

Provider Business Practice Location Address
First Line	:	4040 YALE ST.
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-5928
Country	:	US
Telephone Number	:	713-290-0001
Fax Number	:	713-290-0023

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	TIA GIPSON
Credential	:
Telephone Number	:	713-290-0001

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	03/16/2012

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Directions to “MOTHERLAND, INC. ” Practice Location

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