Organization
CUSTOM REHAB OF SOUTH TEXAS, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LORENA MATTHIESEN (PRESIDENT)
(979) 793-7570
Entity
Organization
Contact information
Practice address
12907 HIGHWAY 36, NEEDVILLE, TX 77461
(979) 793-7570
(979) 793-5540
Mailing address
PO BOX 467, NEEDVILLE, TX 77461-0467
(979) 793-7570
(979) 793-5540
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
332BC3200X
Customized Equipment (DME)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
010008301
—
TX
05
—
011390401
—
TX
01
—
10023796
AMERIGROUP PROVIDER #
TX
01
—
519066
BLUE CROSS BLUE SHIELD
TX
Enumeration date
01/22/2007
Last updated
07/07/2011
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