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General NPI Number Information
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NPI Number | 1285189134
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Entity Type | Organization
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Legal Business Name | 512 PHYSICAL THERAPY AND GOLF PERFORMANCE CENTER
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Dates
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Enumeration Date | 08/22/2016
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Last Update Date | 03/03/2022
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Provider Practice Location Address
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Address Line | 4425 S MOPAC EXPY STE 101
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City | AUSTIN
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State | TX
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Zip | 78735-6710
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Country | US
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Telephone | 512-669-2162
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Fax | 512-572-3272
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Provider Business Mailing Address
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Address Line | 8304 ALOPHIA DR
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City | AUSTIN
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State | TX
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Zip | 78739-1999
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Country | US
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Telephone | 512-699-2162
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ROBERT JEROME ODELL
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Credential | PT
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Telephone | 512-699-2162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State | TX
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