=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467673608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG BALL LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1779 NE LOOP 410 SUITE 100
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-829-7979
-----------------------------------------------------
Fax | 210-829-7979
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1779 NE LOOP 410 SUITE 100
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-829-7979
-----------------------------------------------------
Fax | 210-829-7979
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE-PRESIDENT
-----------------------------------------------------
Name | MR. RODNEY LYNN CROWLEY
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 210-805-9595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1090199
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------