MEDICARE: AMISTAD PHYSICAL THERAPY CLINIC, 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	174400000X	Specialist	649830000/553250000	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	26JB	OTHER	TX	BC/BS GROUP NUMBER
3	351640200	OTHER	TX	US DEPT. OF LABOR GROUP #

General Provider Information

NPI Number	:	1396730297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMISTAD PHYSICAL THERAPY CLINIC, LLC

Provider Business Mailing Address
First Line	:	1308 N BEDELL AVE
Second Line	:
City	:	DEL RIO
State	:	TX
Zip	:	78840-7818
Country	:	US
Telephone Number	:	830-774-1556
Fax Number	:	830-774-6150

Provider Business Practice Location Address
First Line	:	1308 N BEDELL AVE
Second Line	:
City	:	DEL RIO
State	:	TX
Zip	:	78840-7818
Country	:	US
Telephone Number	:	830-774-1556
Fax Number	:	830-774-6150

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	MRS. STEPHANIE ALSUP
Credential	:	P.T.
Telephone Number	:	830-774-1556

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	01/15/2013

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Directions to “AMISTAD PHYSICAL THERAPY CLINIC, LLC ” Practice Location

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