=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750503447
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCPT STAR CARE PHYSICAL THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 N GRANT AVE STE 100
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-4541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-580-7707
-----------------------------------------------------
Fax | 432-580-7937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 N GRANT AVE STE 100
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-4541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-580-7707
-----------------------------------------------------
Fax | 432-580-7937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | RAVI SHAKAMURI
-----------------------------------------------------
Credential | M.S.
-----------------------------------------------------
Telephone | 432-580-7707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------