1033106984 NPI number — SOUTHWEST SPORTS & SPINE V, LLP

Table of content: (NPI 1033106984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033106984 NPI number — SOUTHWEST SPORTS & SPINE V, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST SPORTS & SPINE V, LLP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VISTA PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033106984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5100 W ELDORADO PKWY
Provider Second Line Business Mailing Address:
#102-20KT
Provider Business Mailing Address City Name:
MCKINNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75070-6510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-346-9105
Provider Business Mailing Address Fax Number:
214-346-9125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 TRAVIS ST
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75204-1448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-346-9105
Provider Business Practice Location Address Fax Number:
214-346-9125
Provider Enumeration Date:
10/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RETTKE
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
972-529-3691

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  635850006 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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