Basic Information
| Provider Information | |||||||||
| NPI: | 1447625546 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST TEXAS THERAPEUTIC SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4849 N MESA ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799125919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153516600 | ||||||||
| FaxNumber: | 9153516601 | ||||||||
| Practice Location | |||||||||
| Address1: | 11395 JAMES WATT DR STE A6 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799365941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9156297669 | ||||||||
| FaxNumber: | 9156297679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2015 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | REVELES | ||||||||
| AuthorizedOfficialFirstName: | ADALBERTO | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9159204047 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251G0304X | 1061430 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | 2251P0200X | 1061430 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 2251X0800X | 1061430 | TX | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 1061430 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 179118803 | 05 | TX | MEDICAID | 179118802 | 05 | TX | MEDICAID |