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
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

Other identifiers 1

IdentifierTypeStateIssuer
121835602MedicaidTX

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

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

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": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "121835602",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kilgore, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.