Provider Demographics
NPI:1871654244
Name:EAST TEXAS PEDIATRIC REHABILITATION ASSOCIATES INC
Entity type:Organization
Organization Name:EAST TEXAS PEDIATRIC REHABILITATION ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH CURRIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, PCS
Authorized Official - Phone:903-520-4803
Mailing Address - Street 1:5040 KINSEY DR STE 500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3048
Mailing Address - Country:US
Mailing Address - Phone:903-509-1313
Mailing Address - Fax:903-509-1383
Practice Address - Street 1:5040 KINSEY DR STE 500
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3048
Practice Address - Country:US
Practice Address - Phone:903-509-1313
Practice Address - Fax:903-509-1383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651040000261QR0400X
261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158966501Medicaid