=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851853402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACE MCCLINTOCK PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2019
-----------------------------------------------------
Last Update Date | 04/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 VETERANS MEMORIAL DR
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76504-7451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-743-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 WOLF RANCH PKWY APT 6309
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-7299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-213-7113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 1308307
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------