Basic Information
| Provider Information | |||||||||
| NPI: | 1285764936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINEMATIC CONCEPTS PHYSICAL THERAPY & SPORTS REHAB, PLLC | ||||||||
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| OtherOrganizationName: | MOMENTUM PHYSICAL THERAPY & SPORTS REHAB, PLLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12952 BANDERA RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | HELOTES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780234689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103729600 | ||||||||
| FaxNumber: | 2103729923 | ||||||||
| Practice Location | |||||||||
| Address1: | 12952 BANDERA RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | HELOTES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780234689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103729600 | ||||||||
| FaxNumber: | 2103729923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 01/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | ELMS | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2103729600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MPT, OCS, FAAOMPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 562580001 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 647890002 | TX | Y | 193200000X MULTI-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 | DA8491 | 01 | TX | RAILROAD MEDICARE | OTHER | 1543670-01 | 05 | TX | MEDICAID |