=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083455612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS VALENCIA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2024
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MEDICAL PKWY STE 260
-----------------------------------------------------
City | LAKEWAY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78738-1796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 737-237-0016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2511 ROGERS CV
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-4602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-334-5358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 1392540
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------