Healthcare Provider Details

I. General information

NPI: 1912398348
Provider Name (Legal Business Name): OBACH PHYSICAL THERAPY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 COUNTY ROAD 3801
BULLARD TX
75757
US

IV. Provider business mailing address

4882 HIGHTECH DR
TYLER TX
75703-2613
US

V. Phone/Fax

Practice location:
  • Phone: 903-894-4633
  • Fax: 903-894-4648
Mailing address:
  • Phone: 903-300-0234
  • Fax: 903-630-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1059236
License Number StateTX

VIII. Authorized Official

Name: MS. TRACY CLEMONS
Title or Position: OFFICE MANAGER
Credential:
Phone: 903-300-0234