Healthcare Provider Details

I. General information

NPI: 1730416181
Provider Name (Legal Business Name): LAGO VISTA PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5802 THUNDERBIRD ST. SUITE A
LAGO VISTA TX
78645
US

IV. Provider business mailing address

PO BOX 4649
LAGO VISTA TX
78645
US

V. Phone/Fax

Practice location:
  • Phone: 512-267-5400
  • Fax: 512-267-5700
Mailing address:
  • Phone: 512-267-5400
  • Fax: 512-267-5700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1182499
License Number StateTX

VIII. Authorized Official

Name: NANCY LEIGH COLDICOTT
Title or Position: OWNER
Credential: MSPT
Phone: 512-267-5400