1679236038 NPI number — DISTINCTIVE PHYSICAL THERAPY AND WELLNESS CENTER PLLC

Table of content: (NPI 1679236038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679236038 NPI number — DISTINCTIVE PHYSICAL THERAPY AND WELLNESS CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DISTINCTIVE PHYSICAL THERAPY AND WELLNESS CENTER PLLC
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:
Provider Other Organization Name Type Code:
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:
1679236038
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27495 HALEY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77386-4211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-394-4704
Provider Business Mailing Address Fax Number:
281-768-3602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9201 PINECROFT DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHENANDOAH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77380-3889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-394-4704
Provider Business Practice Location Address Fax Number:
281-768-3602
Provider Enumeration Date:
10/21/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
HOWZE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
281-394-4704

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1208453 . This is a "PHYSICAL THERAPIST" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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