Healthcare Provider Details

I. General information

NPI: 1477206530
Provider Name (Legal Business Name): TRACI S ROSS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2022
Last Update Date: 01/30/2022
Certification Date: 01/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W LIPAN DR
LIPAN TX
76462-2001
US

IV. Provider business mailing address

PO BOX 119
LIPAN TX
76462-0119
US

V. Phone/Fax

Practice location:
  • Phone: 325-716-9443
  • Fax:
Mailing address:
  • Phone: 325-716-9443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1131795
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: