Provider Demographics
NPI:1487169843
Name:ROCKPORT THERAPY CLINIC, LLC
Entity type:Organization
Organization Name:ROCKPORT THERAPY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:LINCOLN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:361-727-6141
Mailing Address - Street 1:1004 E MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-2610
Mailing Address - Country:US
Mailing Address - Phone:361-389-8253
Mailing Address - Fax:
Practice Address - Street 1:1004 E MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-2610
Practice Address - Country:US
Practice Address - Phone:361-389-8253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-07
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)