Provider Demographics
NPI:1992906721
Name:TANGRAM REHABILITATION NETWORK, INC.
Entity type:Organization
Organization Name:TANGRAM REHABILITATION NETWORK, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-7425
Mailing Address - Street 1:1320 WONDER WORLD DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7558
Mailing Address - Country:US
Mailing Address - Phone:512-396-1200
Mailing Address - Fax:512-396-2024
Practice Address - Street 1:5309 TEXAS LONE STAR TRL
Practice Address - Street 2:
Practice Address - City:MAXWELL
Practice Address - State:TX
Practice Address - Zip Code:78656-3610
Practice Address - Country:US
Practice Address - Phone:512-396-8811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX848Medicaid