=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174067466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHOOSE PHYSICAL THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2016
-----------------------------------------------------
Last Update Date | 01/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 E GRIFFIN PKWY STE 120
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-2939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-457-4570
-----------------------------------------------------
Fax | 956-255-7655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 E GRIFFIN PKWY
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-2939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-457-4570
-----------------------------------------------------
Fax | 956-255-7655
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR OF PHYSICAL THERAPY
-----------------------------------------------------
Name | JASON ANGEL MORENO
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 956-457-4570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1248327
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------