Healthcare Provider Details

I. General information

NPI: 1699256073
Provider Name (Legal Business Name): MICHIEL CORD DYSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W BROWN ST
SAN SABA TX
76877-3863
US

IV. Provider business mailing address

209 S COMANCHE DR
DE LEON TX
76444-2007
US

V. Phone/Fax

Practice location:
  • Phone: 325-455-3200
  • Fax:
Mailing address:
  • Phone: 254-979-2856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1190098
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: