Healthcare Provider Details

I. General information

NPI: 1316148992
Provider Name (Legal Business Name): MIDLAND PHYSICAL THERAPY AND SPORTS REHABILITATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 W ILLINOIS AVE
MIDLAND TX
79701-6337
US

IV. Provider business mailing address

PO BOX 932184
ATLANTA GA
31193-2184
US

V. Phone/Fax

Practice location:
  • Phone: 432-687-0235
  • Fax: 432-570-8713
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT158345
License Number StateTX

VIII. Authorized Official

Name: AMANDA STREETER
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 800-699-9395