Healthcare Provider Details

I. General information

NPI: 1649837832
Provider Name (Legal Business Name): TIFFANY RENE SOULES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N SAN MARCOS ST
WHITNEY TX
76692-2652
US

IV. Provider business mailing address

600 RICHARD ST
AQUILLA TX
76622
US

V. Phone/Fax

Practice location:
  • Phone: 254-694-2233
  • Fax:
Mailing address:
  • Phone: 254-266-3233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2066986
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: