Healthcare Provider Details

I. General information

NPI: 1891275673
Provider Name (Legal Business Name): XAVIER DIAZ SOTO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SCENIC DR
GEORGETOWN TX
78626-7725
US

IV. Provider business mailing address

310 GRAND JUNCTION TRL
GEORGETOWN TX
78626-7088
US

V. Phone/Fax

Practice location:
  • Phone: 512-863-9511
  • Fax:
Mailing address:
  • Phone: 432-556-9526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2077452
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: