MEDICARE: MR. ELIAS LOPEZ GALVAN JR. P.T.

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	2251G0304X	Geriatric Physical Therapist	1148279	TX
2	225100000X	Physical Therapist	1148279	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	870T83	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1730258724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ELIAS LOPEZ GALVAN JR. P.T.

Provider Business Mailing Address
First Line	:	3109 JONES RD
Second Line	:
City	:	SUNSET VALLEY
State	:	TX
Zip	:	78745-1334
Country	:	US
Telephone Number	:	512-671-0726
Fax Number	:	512-892-7183

Provider Business Practice Location Address
First Line	:	1825 FORTVIEW RD
Second Line	:	SUITE 109
City	:	AUSTIN
State	:	TX
Zip	:	78704-7657
Country	:	US
Telephone Number	:	512-892-5250
Fax Number	:	512-892-7183

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	11/14/2019

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