Healthcare Provider Details

I. General information

NPI: 1417041518
Provider Name (Legal Business Name): SOUTH AUSTIN THERAPY GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 FORTVIEW RD STE 109
AUSTIN TX
78704-7657
US

IV. Provider business mailing address

1825 FORTVIEW RD SUITE 109
AUSTIN TX
78704-7657
US

V. Phone/Fax

Practice location:
  • Phone: 512-892-5250
  • Fax: 512-892-7183
Mailing address:
  • Phone: 512-892-5250
  • Fax: 512-892-7183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1013902
License Number StateTX

VIII. Authorized Official

Name: MR. ELIAS GALVAN
Title or Position: PRESIDENT, PHYSICAL THERAPIST
Credential: PHYSICAL THERAPIST
Phone: 512-892-5250