=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083023782
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGETOWN PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2014
-----------------------------------------------------
Last Update Date | 08/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3613 WILLIAMS DR SUITE 1004
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-1377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-966-0150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2801 COUNTY ROAD 152
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-1982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-966-0150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TERESA POINDEXTER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 512-966-0150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 1220578
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------