Basic Information
| Provider Information | |||||||||
| NPI: | 1336100015 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINEMATIC CONCEPTS PHYSICAL THERAPY & SPORTS REHAB | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MOMENTUM PHYSICAL THERAPY & SPORTS REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12952 BANDERA RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | HELOTES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780234689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106952682 | ||||||||
| FaxNumber: | 2105980432 | ||||||||
| Practice Location | |||||||||
| Address1: | 12952 BANDERA RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | HELOTES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780234689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103729600 | ||||||||
| FaxNumber: | 2103729923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELMS | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO / CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2103729600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KINEMATIC CONCEPTS PHYSICAL THERAPY & SPORTS REHAB, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPT, OCS, FAAOPMT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 647890000 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 647890002 | TX | Y | 193400000X MULTIPLE 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 | 1543670-01 | 05 | TX | MEDICAID |