MEDICARE: PREMIER THERAPEUTIC OCC REHABILITATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1095537	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1095537	OTHER	TX	TX BOARD PT/OT LICENSE

General Provider Information

NPI Number	:	1427003839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER THERAPEUTIC OCC REHABILITATION

Provider Business Mailing Address
First Line	:	6127 SAN PEDRO
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-7204
Country	:	US
Telephone Number	:	210-340-3455
Fax Number	:

Provider Business Practice Location Address
First Line	:	6127 SAN PEDRO
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-7204
Country	:	US
Telephone Number	:	210-340-3455
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MONIQUE GARZA
Credential	:
Telephone Number	:	210-340-3455

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	08/22/2020

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