NPIMap

Organization Active NPI

East Texas Treatment Center

  • Comprehensive Outpatient Rehabilitation Facility (CORF)
  • Kilgore, TX
National Provider Identifier
1023002425
Registry record updated Feb 17, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Comprehensive Outpatient Rehabilitation Facility (CORF)Taxonomy code 261QR0401X
Legal business name
EAST TEXAS TREATMENT CENTER
Practice address
1200 Dudley Rd
Kilgore, TX 75662-3306
Phone
(903) 984-5571
Fax
(903) 984-1913
NPI assigned
Aug 31, 2005
Last updated
Feb 17, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 17, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Terry Hardan
Title
Executive Director
Phone
(903) 984-5571

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225100000X 605680000 TX
Comprehensive Outpatient Rehabilitation Facility (CORF) 261QR0401X TX Primary

Addresses

Primary practice location

1200 Dudley Rd
Kilgore, TX 75662-3306

Mailing address

1200 Dudley Rd
Kilgore, TX 75662-3306
Phone (903) 984-5571

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20060110000700 TX Part B Supplier - Clinic/Group Practice 0244253854 Receives reassigned benefits from 1 practitioner
Practice locations: Kilgore, TX
O20100513000802 TX Part A Provider - Comprehensive Outpatient Rehabilitation Facility 0244253854 Practice locations: Kilgore, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1023002425. Details of each certification follow.

  • CCN 454512 Comprehensive outpatient rehabilitation facility · Active · Name & address match · Details

Comprehensive outpatient rehabilitation facility certification: CCN 454512

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
EAST TEXAS TREATMENT CTR
Certification status
Active
Provider type (POS)
Comprehensive outpatient rehabilitation facility
Participating since
Jun 6, 1991
Last certification
Sep 7, 2022
Ownership / control type
Other
Facility address
1200 Dudley Rd Box 1599
Kilgore, TX 75662

National Provider Directory

National Provider Directory

Locations

1200 Dudley Rd
Kilgore, TX 75662
Phone (903) 984-5571

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1125446400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1645056000000",
    "number": "1023002425",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 DUDLEY RD",
            "city": "KILGORE",
            "state": "TX",
            "postal_code": "756623306",
            "telephone_number": "903-984-5571",
            "fax_number": "903-984-1913"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1200 DUDLEY RD",
            "city": "KILGORE",
            "state": "TX",
            "postal_code": "756623306",
            "telephone_number": "903-984-5571",
            "fax_number": "903-984-1913"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TEXAS TREATMENT CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-31",
        "last_updated": "2022-02-17",
        "certification_date": "2022-02-17",
        "status": "A",
        "authorized_official_last_name": "HARDAN",
        "authorized_official_first_name": "TERRY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "903-984-5571"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": "TX",
            "license": "605680000",
            "primary": false
        },
        {
            "code": "261QR0401X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)",
            "state": "TX",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Kilgore, TX

Sources for this page

Verify at the official NPI Registry.