Healthcare Provider Details

I. General information

NPI: 1053892851
Provider Name (Legal Business Name): ALEXIS ILSE PT, MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 GENERAL CAVAZOS BLVD
KINGSVILLE TX
78363-7130
US

IV. Provider business mailing address

3727 ANDRON ST
KINGSVILLE TX
78363-7418
US

V. Phone/Fax

Practice location:
  • Phone: 361-595-9405
  • Fax:
Mailing address:
  • Phone: 361-816-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1183180
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: