Healthcare Provider Details

I. General information

NPI: 1548738099
Provider Name (Legal Business Name): TIBIN PRINCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 WATERVIEW PKWY
RICHARDSON TX
75080-1400
US

IV. Provider business mailing address

12508 JONES MALTSBERGER RD STE 110
SAN ANTONIO TX
78247-4215
US

V. Phone/Fax

Practice location:
  • Phone: 972-332-4682
  • Fax:
Mailing address:
  • Phone: 888-590-4002
  • Fax: 210-590-4585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1312735
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: