Healthcare Provider Details

I. General information

NPI: 1336248863
Provider Name (Legal Business Name): ROBERTO HWANG ICO P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 S LOOP 289 11
LUBBOCK TX
79424-2208
US

IV. Provider business mailing address

5715 83RD LN
LUBBOCK TX
79424-4631
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-7200
  • Fax: 806-792-7225
Mailing address:
  • Phone: 806-794-5329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1035814
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: