=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255686374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ZOOM PHYSICAL THERAPY AND WELLNESS, P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2012
-----------------------------------------------------
Last Update Date | 09/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2806 N MAIN ST
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901-3216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-237-1670
-----------------------------------------------------
Fax | 361-237-1703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3502
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77903-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-237-1670
-----------------------------------------------------
Fax | 361-237-1703
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | MR. FRANK JONATHAN STEFKA
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 361-648-1592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 109364
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1135507
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------