Healthcare Provider Details

I. General information

NPI: 1023282811
Provider Name (Legal Business Name): MEDINA VALLEY SPINE AND JOINT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 US HIGHWAY 90 W SUITE 2
CASTROVILLE TX
78009-4540
US

IV. Provider business mailing address

209 US HIGHWAY 90 W SUITE 2
CASTROVILLE TX
78009-4540
US

V. Phone/Fax

Practice location:
  • Phone: 830-931-2211
  • Fax: 830-538-3778
Mailing address:
  • Phone: 830-931-2211
  • Fax: 830-538-3778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number109851
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC6704
License Number StateTX

VIII. Authorized Official

Name: DR. ERNEST CONRAD KOTHMANN
Title or Position: MANAGING MEMBER
Credential: DC
Phone: 830-931-2211