MEDICARE: LITTLE STAR REHAB

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	305S00000X	Point of Service
2	261QR0400X	Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1477812857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE STAR REHAB

Provider Business Mailing Address
First Line	:	4525 ALTAMESA BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133
Country	:	US
Telephone Number	:	817-822-9195
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 ALTAMESA BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133
Country	:	US
Telephone Number	:	817-822-9195
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ANGELA WATSON
Credential	:
Telephone Number	:	817-822-9195

Provider Enumeration Date	:	05/07/2012
Last Update Date	:	11/19/2012

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Directions to “LITTLE STAR REHAB ” Practice Location

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