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General NPI Number Information
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NPI Number | 1417189424
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Entity Type | Organization
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Legal Business Name | BALANCE DIZZINESS & PHYSICAL THERAPY CLINIC, LLC
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Dates
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Enumeration Date | 08/10/2009
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Last Update Date | 02/06/2010
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Provider Practice Location Address
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Address Line | 3560 DELAWARE ST SUITE 1002
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City | BEAUMONT
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State | TX
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Zip | 77706-3067
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Country | US
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Telephone | 409-899-1100
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Fax | 409-899-1120
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Provider Business Mailing Address
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Address Line | 3560 DELAWARE ST SUITE 1002
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City | BEAUMONT
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State | TX
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Zip | 77706-3067
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Country | US
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Telephone | 409-899-1100
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Fax | 409-899-1120
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MS. ANNE FERNANDO
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Credential | OTR
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Telephone | 409-899-1100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 108802
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1113884
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License Number State | TX
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