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General NPI Number Information
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NPI Number | 1770834665
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Entity Type | Individual
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Provider Name | IMMANUEL KARLO GALLETA MEDINA P.T.
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Gender | Male
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Dates
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Enumeration Date | 10/02/2012
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Last Update Date | 11/06/2020
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Provider Practice Location Address
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Address Line | 8758 WELLES EDGE DR
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City | SAN ANTONIO
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State | TX
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Zip | 78240
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Country | US
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Telephone | 408-449-8150
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Fax |
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Provider Business Mailing Address
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Address Line | 8758 WELLES EDGE DR
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City | SAN ANTONIO
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State | TX
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Zip | 78240-2115
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Country | US
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Telephone | 408-449-8150
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 1217753
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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 | 299318
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License Number State | CA
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