=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083933097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH TEXAS SPORTS MEDICINE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2010
-----------------------------------------------------
Last Update Date | 09/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1007 FM 3036
-----------------------------------------------------
City | FULTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-729-8668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5530 LIPES BLVD
-----------------------------------------------------
City | CORPUS CHRISTI
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-993-9494
-----------------------------------------------------
Fax | 361-993-4477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DONALD RAY ZYLKS
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 361-728-4288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 604380002
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------