Healthcare Provider Details

I. General information

NPI: 1134356231
Provider Name (Legal Business Name): TEXAS A&M UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 WELLBORN RD BRIGHT FOOTBALL COMPLEX
COLLEGE STATION TX
77843-0001
US

IV. Provider business mailing address

PO BOX 30017
COLLEGE STATION TX
77842-3017
US

V. Phone/Fax

Practice location:
  • Phone: 979-845-3121
  • Fax: 979-847-8514
Mailing address:
  • Phone: 979-845-3121
  • Fax: 979-847-8514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1165990
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateTX

VIII. Authorized Official

Name: MATTHEW SCOTT KEE
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 979-845-3121