Basic Information
| Provider Information | |||||||||
| NPI: | 1790341337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAHIWALA | ||||||||
| FirstName: | JALDHIBEN | ||||||||
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| OtherLastName: | SHAHIWALE | ||||||||
| OtherFirstName: | JALDHIBEN | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 928 GLEN LAKE DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760921526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097283670 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6225 N STATE HIGHWAY 161 STE 350 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750382256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179162101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2019 | ||||||||
| LastUpdateDate: | 05/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1305790 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.