MEDICARE: MOBILE SPINE SPECIALIST LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1033743968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE SPINE SPECIALIST LLC

Provider Business Mailing Address
First Line	:	601 QUAIL VALLEY DR
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-8051
Country	:	US
Telephone Number	:	512-559-6551
Fax Number	:	512-591-0789

Provider Business Practice Location Address
First Line	:	601 QUAIL VALLEY DR
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-8051
Country	:	US
Telephone Number	:	512-559-6551
Fax Number	:	512-591-0789

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/OWNER
Name	:	MR. JEFFREY LUM
Credential	:	PT, MPT, DIP. MDT
Telephone Number	:	512-559-6551

Provider Enumeration Date	:	03/01/2020
Last Update Date	:	11/20/2020

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