MEDICARE: REHAB RANCH OF EL PASO, LLC

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	225X00000X	Occupational Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0095MX	OTHER	TX	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1457366254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REHAB RANCH OF EL PASO, LLC

Provider Business Mailing Address
First Line	:	6666 MORRILL RD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79932-2608
Country	:	US
Telephone Number	:	915-877-5602
Fax Number	:	915-877-7308

Provider Business Practice Location Address
First Line	:	6666 MORRILL RD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79932-2608
Country	:	US
Telephone Number	:	915-877-5602
Fax Number	:	915-877-7308

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KATHLEEN MARIE CONDON
Credential	:
Telephone Number	:	915-581-1198

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	07/25/2007

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