Healthcare Provider Details

I. General information

NPI: 1831053586
Provider Name (Legal Business Name): LEO BANTILING GARRA III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2483 2ND ST STE B
EAGLE PASS TX
78852-4391
US

IV. Provider business mailing address

2101 N 23RD ST
MCALLEN TX
78501-6127
US

V. Phone/Fax

Practice location:
  • Phone: 830-776-5191
  • Fax: 830-776-5205
Mailing address:
  • Phone: 956-687-4559
  • Fax: 956-687-4560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1398540
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: