MEDICARE: ORTHO KINEMATICS

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	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1164848420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHO KINEMATICS

Provider Business Mailing Address
First Line	:	110 WILD BASIN RD
Second Line	:	SUITE 250
City	:	WEST LAKE HILLS
State	:	TX
Zip	:	78746-3339
Country	:	US
Telephone Number	:	512-334-5490
Fax Number	:	512-334-5500

Provider Business Practice Location Address
First Line	:	110 WILD BASIN RD
Second Line	:	SUITE 250
City	:	WEST LAKE HILLS
State	:	TX
Zip	:	78746-3339
Country	:	US
Telephone Number	:	512-334-5490
Fax Number	:	512-334-5500

Authorized Official
Title or Position	:	VICE PRESIDENT CLIENT DEVELOPMENT
Name	:	JASON GARRETT
Credential	:
Telephone Number	:	512-334-5490

Provider Enumeration Date	:	03/11/2014
Last Update Date	:	03/11/2014

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