MEDICARE: DYNAMIC EVALUATION CENTER OF SOUTH TEXAS, 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	225X00000X	Occupational Therapist		TX
2	225100000X	Physical Therapist		TX

General Provider Information

NPI Number	:	1952301145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC EVALUATION CENTER OF SOUTH TEXAS, LLC

Provider Business Mailing Address
First Line	:	5920 SARATOGA BLVD
Second Line	:	SUITE 645
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78414-4103
Country	:	US
Telephone Number	:	361-851-0209
Fax Number	:	361-851-0147

Provider Business Practice Location Address
First Line	:	5920 SARATOGA BLVD
Second Line	:	SUITE 645
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78414-4103
Country	:	US
Telephone Number	:	361-851-0209
Fax Number	:	361-851-0147

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. DIANA H RODRIGUEZ
Credential	:	NCMOA
Telephone Number	:	361-851-0209

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	12/19/2007

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