MEDICARE: REHAB-BACK CARE INSTITUTE OF WEST TEXAS

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	261QP2000X	Physical Therapy Clinic/Center	DC5710	TX

General Provider Information

NPI Number	:	1235463639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REHAB-BACK CARE INSTITUTE OF WEST TEXAS

Provider Business Mailing Address
First Line	:	1030 N GRANDVIEW AVE
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-3149
Country	:	US
Telephone Number	:	432-332-3388
Fax Number	:	432-332-3390

Provider Business Practice Location Address
First Line	:	1030 N GRANDVIEW AVE
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-3149
Country	:	US
Telephone Number	:	432-332-3388
Fax Number	:	432-332-3390

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARK DAVID MEHAFFEY
Credential	:	DC
Telephone Number	:	432-332-3388

Provider Enumeration Date	:	10/01/2009
Last Update Date	:	10/01/2009

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