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NPI Code Detail

MEDICARE: TX770911-002, LLC

MEDICARE: TX770911-002, 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
1111N00000XChiropractorCHIA-1275ID
2225100000XPhysical Therapist1190830TX

General Provider Information

NPI Number : 1629356761
Entity Type Code : Organization
Provider Name (Legal Business Name) : TX770911-002, LLC
Provider Business Mailing Address
First Line : 608 SANDAU RD
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78216-4131
Country : US
Telephone Number : 210-564-0100
Fax Number : 210-564-0157
Provider Business Practice Location Address
First Line : 1117 CLEAR LK CTY BLVD
Second Line :
City : HOUSTON
State : TX
Zip : 77062-8102
Country : US
Telephone Number : 281-401-9789
Fax Number : 281-401-9779
Authorized Official
Title or Position : OWNER
Name : THOMAS MARTIN TOMERLIN
Credential :
Telephone Number : 210-564-0100
Provider Enumeration Date : 07/22/2011
Last Update Date : 09/07/2012

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