=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114113412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOURDES L KERESZTES MSPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2007
-----------------------------------------------------
Last Update Date | 09/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3851 ROGER BROOKE DR
-----------------------------------------------------
City | FORT SAM HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78234-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-916-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 925 SAN FERNANDO LN
-----------------------------------------------------
City | NEW BRAUNFELS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78132-2900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-214-6863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1174138
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------