=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417117847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAMROCK PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2008
-----------------------------------------------------
Last Update Date | 06/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1611 FM 318 E
-----------------------------------------------------
City | YOAKUM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77995-6705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-293-5532
-----------------------------------------------------
Fax | 800-834-8051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1611 FM 318 E
-----------------------------------------------------
City | YOAKUM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77995-6705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-293-5532
-----------------------------------------------------
Fax | 800-934-8051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | MRS. KRISTI LEIGH KAISER
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 361-293-5532
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 601940022
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------