Healthcare Provider Details

I. General information

NPI: 1861969230
Provider Name (Legal Business Name): IVAN TIO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14655 PRESTON RD
DALLAS TX
75254-7805
US

IV. Provider business mailing address

14655 PRESTON RD
DALLAS TX
75254-7805
US

V. Phone/Fax

Practice location:
  • Phone: 972-726-7575
  • Fax:
Mailing address:
  • Phone: 972-726-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2141029
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: