=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831053586
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEO BANTILING GARRA III
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2025
-----------------------------------------------------
Last Update Date | 12/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2483 2ND ST STE B
-----------------------------------------------------
City | EAGLE PASS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78852-4391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-776-5191
-----------------------------------------------------
Fax | 830-776-5205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 N 23RD ST
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78501-6127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-687-4559
-----------------------------------------------------
Fax | 956-687-4560
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1398540
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------