=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396730297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMISTAD PHYSICAL THERAPY CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2005
-----------------------------------------------------
Last Update Date | 01/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1308 N BEDELL AVE
-----------------------------------------------------
City | DEL RIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78840-7818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-774-1556
-----------------------------------------------------
Fax | 830-774-6150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1308 N BEDELL AVE
-----------------------------------------------------
City | DEL RIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78840-7818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-774-1556
-----------------------------------------------------
Fax | 830-774-6150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | MRS. STEPHANIE ALSUP
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 830-774-1556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 649830000/553250000
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------