MEDICARE: WEST PARK REHAB & AQUATIC CENTER

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

General Provider Information

NPI Number	:	1407113525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST PARK REHAB & AQUATIC CENTER

Provider Business Mailing Address
First Line	:	210 W PARK
Second Line	:	SUITE 101
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-8336
Country	:	US
Telephone Number	:	936-327-8080
Fax Number	:	936-327-8086

Provider Business Practice Location Address
First Line	:	210 W PARK
Second Line	:	SUITE 101
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-8336
Country	:	US
Telephone Number	:	936-327-8080
Fax Number	:	936-327-8086

Authorized Official
Title or Position	:	GENERAL PARTNER
Name	:	TIMOTHY S SHAW
Credential	:	M.D., P.A.
Telephone Number	:	936-328-8080

Provider Enumeration Date	:	04/13/2012
Last Update Date	:	07/26/2012

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