MEDICARE: SOPHIA WENDEBORN II PTA

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	2027662	TX
2	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1427441310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA WENDEBORN II PTA

Provider Business Mailing Address
First Line	:	1111 SE MILITARY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78214-2801
Country	:	US
Telephone Number	:	210-924-4475
Fax Number	:	210-924-9251

Provider Business Practice Location Address
First Line	:	1111 SE MILITARY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78214-2801
Country	:	US
Telephone Number	:	210-924-4475
Fax Number	:	210-924-9251

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2015
Last Update Date	:	10/11/2021

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