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General NPI Number Information
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NPI Number | 1659528610
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Entity Type | Organization
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Legal Business Name | PRACTIVA HEALTH LLC
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Dates
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Enumeration Date | 08/21/2008
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Last Update Date | 08/21/2008
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Provider Practice Location Address
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Address Line | 5282 MEDICAL DR SUITE 205A
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City | SAN ANTONIO
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State | TX
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Zip | 78229-4849
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Country | US
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Telephone | 210-949-0070
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Fax | 210-949-0277
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Provider Business Mailing Address
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Address Line | 29144 OLD FREDERICKSBURG RD
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City | BOERNE
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State | TX
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Zip | 78015-9101
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Country | US
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Telephone | 210-949-0070
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Fax | 210-949-0277
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Authorized Official
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Title or Position | OWNER
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Name | MR. PIETER LAURUS DE SMIDT
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Credential | PT
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Telephone | 210-949-0070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 1072643
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License Number State | TX
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