Healthcare Provider Details

I. General information

NPI: 1083933097
Provider Name (Legal Business Name): SOUTH TEXAS SPORTS MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 FM 3036
FULTON TX
78358
US

IV. Provider business mailing address

5530 LIPES BLVD
CORPUS CHRISTI TX
78413
US

V. Phone/Fax

Practice location:
  • Phone: 361-729-8668
  • Fax:
Mailing address:
  • Phone: 361-993-9494
  • Fax: 361-993-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number604380002
License Number StateTX

VIII. Authorized Official

Name: DONALD RAY ZYLKS
Title or Position: PRESIDENT
Credential: PHD
Phone: 361-728-4288