MEDICARE: TX770911-002, LLC

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	111N00000X	Chiropractor	CHIA-1275	ID
2	225100000X	Physical Therapist	1190830	TX

General Provider Information

NPI Number	:	1629356761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TX770911-002, LLC

Provider Business Mailing Address
First Line	:	608 SANDAU RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-4131
Country	:	US
Telephone Number	:	210-564-0100
Fax Number	:	210-564-0157

Provider Business Practice Location Address
First Line	:	1117 CLEAR LK CTY BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77062-8102
Country	:	US
Telephone Number	:	281-401-9789
Fax Number	:	281-401-9779

Authorized Official
Title or Position	:	OWNER
Name	:	THOMAS MARTIN TOMERLIN
Credential	:
Telephone Number	:	210-564-0100

Provider Enumeration Date	:	07/22/2011
Last Update Date	:	09/07/2012

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