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General NPI Number Information
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NPI Number | 1588703557
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Entity Type | Organization
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Legal Business Name | LAKE WHITNEY PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 07/15/2010
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Provider Practice Location Address
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Address Line | 204 EAST JEFFERSON
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City | WHITNEY
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State | TX
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Zip | 76692
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Country | US
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Telephone | 254-694-6831
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 68
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City | WHITNEY
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State | TX
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Zip | 76692-0068
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Country | US
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Telephone | 254-694-6831
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | TODD J WAGNER
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Credential | MSPT
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Telephone | 254-694-6831
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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 |
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