MEDICARE: ALTA VISTA HEALTHCARE, LP

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	225100000X	Physical Therapist	1038107

General Provider Information

NPI Number	:	1508871989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTA VISTA HEALTHCARE, LP

Provider Business Mailing Address
First Line	:	5445 LA SIERRA DR
Second Line	:	SUITE 204
City	:	DALLAS
State	:	TX
Zip	:	75231-4139
Country	:	US
Telephone Number	:	214-692-6666
Fax Number	:	214-692-6670

Provider Business Practice Location Address
First Line	:	1123 N MAIN AVE
Second Line	:	SUITE 100
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-4740
Country	:	US
Telephone Number	:	210-822-6323
Fax Number	:	210-822-6356

Authorized Official
Title or Position	:	CEO
Name	:	MR. NATHANIEL E. MANGUM
Credential	:
Telephone Number	:	214-692-6666

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	08/22/2020

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