Basic Information
| Provider Information | |||||||||
| NPI: | 1215037411 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMPREHENSIVE PHYSICAL THERAPY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2805 | ||||||||
| Address2: | |||||||||
| City: | BANDERA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307963447 | ||||||||
| FaxNumber: | 8307963685 | ||||||||
| Practice Location | |||||||||
| Address1: | 3456 HWY 16 SOUTH | ||||||||
| Address2: | |||||||||
| City: | BANDERA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307963447 | ||||||||
| FaxNumber: | 8307963685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 10/12/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GASCOT | ||||||||
| AuthorizedOfficialFirstName: | CARMEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8307963447 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT10676678 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00159591 | 01 | TX | MEDICARE RAILROAD | OTHER | 8T2788 | 01 | TX | BCBS | OTHER |