Healthcare Provider Details

I. General information

NPI: 1952423766
Provider Name (Legal Business Name): TIMOTHY J PENDERGRASS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4214 98TH ST
LUBBOCK TX
79423-3957
US

IV. Provider business mailing address

3419 22ND ST
LUBBOCK TX
79410-1334
US

V. Phone/Fax

Practice location:
  • Phone: 806-712-7878
  • Fax: 806-722-7878
Mailing address:
  • Phone: 806-796-3000
  • Fax: 806-796-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1167979
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: