Healthcare Provider Details

I. General information

NPI: 1174677405
Provider Name (Legal Business Name): CARLOS M ESCAMILLA P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5411 MCPHERSON RD STE 109
LAREDO TX
78041-6834
US

IV. Provider business mailing address

5411 MCPHERSON RD STE 109
LAREDO TX
78041-6834
US

V. Phone/Fax

Practice location:
  • Phone: 956-753-6100
  • Fax: 956-753-6117
Mailing address:
  • Phone: 956-753-6100
  • Fax: 956-753-6117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1042638
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: