Healthcare Provider Details

I. General information

NPI: 1376579797
Provider Name (Legal Business Name): TILLMAN PHYSICAL THERAPY & SPORTS TRAINING CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 S LAKELINE BLVD SUITE 100
CEDAR PARK TX
78613-2964
US

IV. Provider business mailing address

2519 S LAKELINE BLVD SUITE 100
CEDAR PARK TX
78613-2964
US

V. Phone/Fax

Practice location:
  • Phone: 512-331-6200
  • Fax: 512-331-4312
Mailing address:
  • Phone: 512-331-6200
  • Fax: 512-331-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number554280000
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number644350000
License Number StateTX

VIII. Authorized Official

Name: MICHAEL RAY TILLMAN
Title or Position: PHYICAL THERAPIST PRESIDENT
Credential: MPT, CSCS, CERT. MDT
Phone: 512-331-6200