Basic Information
| Provider Information | |||||||||
| NPI: | 1528260221 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFORMANCE THERAPEUTICS-RIO GRANDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 LINDBERG AVE | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785012924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566874560 | ||||||||
| FaxNumber: | 9566181342 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 N FM 3167 | ||||||||
| Address2: | UNIT E | ||||||||
| City: | RIO GRANDE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785826207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564881999 | ||||||||
| FaxNumber: | 9564881616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | PALOMIN | ||||||||
| AuthorizedOfficialFirstName: | OMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9566874559 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1139541 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0098QA | 01 | TX | BC/BS PROVIDER # | OTHER | 613041800 | 01 | TX | WORKERS' COMPENSATION | OTHER |