1861556508 NPI number — IMPACT PHYSICAL THERAPY, L.L.C.

Table of content: MELISSA DAVID CLAMOR OTRL (NPI 1982804423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861556508 NPI number — IMPACT PHYSICAL THERAPY, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMPACT PHYSICAL THERAPY, L.L.C.
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:
1861556508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N. HWY 77
Provider Second Line Business Mailing Address:
SUITE N
Provider Business Mailing Address City Name:
RAYMONDVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78580-4010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-689-9195
Provider Business Mailing Address Fax Number:
956-659-9217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N. HWY 77
Provider Second Line Business Practice Location Address:
SUITE N
Provider Business Practice Location Address City Name:
RAYMONDVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78580-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-689-9195
Provider Business Practice Location Address Fax Number:
956-659-9217
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SPANIHEL
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
956-689-9195

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  1056786 , 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)

  • Identifier: 116160 . This is a "SUPERIOR HEALTHPLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 659445 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 021737402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 021737401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107970903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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