MEDICARE: LAKE JACKSON REHABILITATION AND WELLNESS 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	225100000X	Physical Therapist	650330002	TX

General Provider Information

NPI Number	:	1952346264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE JACKSON REHABILITATION AND WELLNESS CENTER

Provider Business Mailing Address
First Line	:	242 FLAMINGO ISLAND DR
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4611
Country	:	US
Telephone Number	:	281-802-1441
Fax Number	:	713-634-2697

Provider Business Practice Location Address
First Line	:	117 CIRCLE WAY ST
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5233
Country	:	US
Telephone Number	:	979-480-9400
Fax Number	:	979-480-9410

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. DANIEL DOMINGUEZ
Credential	:
Telephone Number	:	281-802-1441

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	05/14/2010

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