Healthcare Provider Details

I. General information

NPI: 1457831463
Provider Name (Legal Business Name): HERMAN KENDALL SELTZER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2018
Last Update Date: 08/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 N GRAPEVINE MILLS BLVD APT 2417
GRAPEVINE TX
76051-2072
US

IV. Provider business mailing address

3800 MARINA DR
FORT WORTH TX
76135-2835
US

V. Phone/Fax

Practice location:
  • Phone: 210-488-0330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2123596
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: