Basic Information
| Provider Information | |||||||||
| NPI: | 1790065845 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXAS KIDS HOME THERAPY PROFESSIONAL LIMITED LIABILITY COMPANY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TEXAS KIDS HOME THERAY AND NURSING PROFESSIONAL LIMITED LIABILITY COMP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 555 PRADO XING | ||||||||
| Address2: | |||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780068260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103601662 | ||||||||
| FaxNumber: | 2105682228 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 UPPER BALCONES RD | ||||||||
| Address2: | |||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780068546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103601662 | ||||||||
| FaxNumber: | 2105682228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2011 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KURTZ | ||||||||
| AuthorizedOfficialFirstName: | DERSHIE | ||||||||
| AuthorizedOfficialMiddleName: | BRIDGFORD | ||||||||
| AuthorizedOfficialTitleorPosition: | ALTERNATE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2102746676 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | 014370 | TX | N | Agencies | Nursing Care | 3747P1801X | 014370 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Technician | Personal Care Attendant | 385H00000X | 014370 | TX | N | Respite Care Facility | Respite Care | 251E00000X | Y | Agencies | Home Health |
No ID Information.