Provider Demographics
NPI:1154567568
Name:SAFARI KIDS REHABILITATION CENTER,LLC
Entity type:Organization
Organization Name:SAFARI KIDS REHABILITATION CENTER,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER,SPEECH LANGUAGE PATHOLOGIS
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESMERALDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:956-568-4675
Mailing Address - Street 1:2108 CHIHUAHUA ST
Mailing Address - Street 2:SUITE#2
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043-3657
Mailing Address - Country:US
Mailing Address - Phone:956-568-4675
Mailing Address - Fax:956-568-4671
Practice Address - Street 1:2108 CHIHUAHUA ST
Practice Address - Street 2:SUITE# 3
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78043-3658
Practice Address - Country:US
Practice Address - Phone:956-568-4675
Practice Address - Fax:956-568-4671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
TX111552225X00000X
TX100691235Z00000X
TX676667261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNO NUMBERS AVAILABLE