1215428909 NPI number — EL PASO MANUAL PHYSICAL THERAPY PLLC

Table of content: (NPI 1215428909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215428909 NPI number — EL PASO MANUAL PHYSICAL THERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EL PASO MANUAL PHYSICAL THERAPY 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:
EL PASO MANUAL PHYSICAL THERAPY, PLLC
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:
1215428909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3900 JEFFERSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79930-6614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-329-6805
Provider Business Mailing Address Fax Number:
915-255-3826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 E YANDELL DR STE 232
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79903-3724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-503-1314
Provider Business Practice Location Address Fax Number:
915-255-3826
Provider Enumeration Date:
05/29/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MIDDAUGH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR, OWNER
Authorized Official Telephone Number:
915-503-1314

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1207709 , 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: 1207709 . This is a "TEXAS PHYSICAL THERAPY LICENSE" identifier . This identifiers is of the category "OTHER".




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