1568538049 NPI number — 9TH AVENUE PHYSICAL THERAPY, PLLC

Table of content: (NPI 1568538049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568538049 NPI number — 9TH AVENUE PHYSICAL THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
9TH AVENUE 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:
Provider Other Organization Name Type Code:
6
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:
1568538049
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1488
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROVES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77619-1488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-466-7139
Provider Business Mailing Address Fax Number:
409-729-8114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8333 9TH AVE.
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
PORT ARTHUR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-729-8111
Provider Business Practice Location Address Fax Number:
409-729-8114
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANUEL
Authorized Official First Name:
RENE
Authorized Official Middle Name:
SOAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
409-466-7138

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  1047017 , 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: 3960760 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 3714404 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 98ME . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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