Provider Demographics
NPI:1902959422
Name:LASER REHABILITATION CLINIC
Entity Type:Organization
Organization Name:LASER REHABILITATION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:S
Authorized Official - Last Name:EARL
Authorized Official - Suffix:
Authorized Official - Credentials:LILT AND BCHIS
Authorized Official - Phone:409-882-0696
Mailing Address - Street 1:3212 CONCORD DRIVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630
Mailing Address - Country:US
Mailing Address - Phone:409-882-0696
Mailing Address - Fax:409-882-0427
Practice Address - Street 1:3212 CONCORD DRIVE
Practice Address - Street 2:SUITE E
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630
Practice Address - Country:US
Practice Address - Phone:409-882-0696
Practice Address - Fax:409-882-0427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX50306OtherHEARING AID SPECIALIST
TX022433901Medicaid
TX022433901Medicaid