Provider Demographics
NPI:1538171996
Name:EL DORADO REHABILITATION SERVICES, INC
Entity type:Organization
Organization Name:EL DORADO REHABILITATION SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-863-7900
Mailing Address - Street 1:PO BOX 9600
Mailing Address - Street 2:DEPARTMENT 09012
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-9600
Mailing Address - Country:US
Mailing Address - Phone:870-863-7900
Mailing Address - Fax:870-863-7901
Practice Address - Street 1:704 S TIMBERLANE DR
Practice Address - Street 2:SUITE 11
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-6929
Practice Address - Country:US
Practice Address - Phone:870-863-7900
Practice Address - Fax:870-863-7901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C927Medicare ID - Type UnspecifiedGROUP