Provider Demographics
NPI:1285703397
Name:CUSTOM REHAB OF NORTH TEXAS, INC.
Entity type:Organization
Organization Name:CUSTOM REHAB OF NORTH TEXAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:CRTS
Authorized Official - Phone:214-744-3606
Mailing Address - Street 1:810 S SAINT PAUL ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-6216
Mailing Address - Country:US
Mailing Address - Phone:214-744-3606
Mailing Address - Fax:214-744-3609
Practice Address - Street 1:810 S SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-6216
Practice Address - Country:US
Practice Address - Phone:214-744-3606
Practice Address - Fax:214-744-3609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0085543332B00000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX515568OtherBLUE CROSS
TXOPDME=========OtherTEXAS WORKERS COMP.
TX0411720001Medicare ID - Type UnspecifiedMEDICARE