Healthcare Provider Details

I. General information

NPI: 1306496609
Provider Name (Legal Business Name): BALA NIKLESH REDDY POTHIREDDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 GENERAL CAVAZOS BLVD
KINGSVILLE TX
78363-7150
US

IV. Provider business mailing address

1311 GENERAL CAVAZOS BLVD
KINGSVILLE TX
78363-7150
US

V. Phone/Fax

Practice location:
  • Phone: 361-595-9405
  • Fax:
Mailing address:
  • Phone: 361-595-1661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1270686
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: