Basic Information
Provider Information | |||||||||
NPI: | 1023079712 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KINEMATIC CONCEPTS PHYSICAL THERAPY & SPORTS REHAB, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOMENTUM PHYSICAL THERAPY & SPORTS REHAB | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12952 BANDERA RD | ||||||||
Address2: | SUITE 107 | ||||||||
City: | HELOTES | ||||||||
State: | TX | ||||||||
PostalCode: | 780234689 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2106952682 | ||||||||
FaxNumber: | 2103720211 | ||||||||
Practice Location | |||||||||
Address1: | 5441 BABCOCK RD | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782403989 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2102533888 | ||||||||
FaxNumber: | 2102533889 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 04/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MALFER | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT / CO-OWNER | ||||||||
AuthorizedOfficialTelephone: | 2102533888 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KINEMATIC CONCEPTS PHYSICAL THERAPY & SPORTS REHAB, PLLC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT, ATC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 647890001 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 0084HN | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |