Basic Information
| Provider Information | |||||||||
| NPI: | 1831491760 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALTA MESA PHYSICAL THERAPY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 E SCHUSTER AVE | ||||||||
| Address2: | SUITE 9A | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799024350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155444100 | ||||||||
| FaxNumber: | 9155444102 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 E SCHUSTER AVE | ||||||||
| Address2: | SUITE 9A | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799024350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155444100 | ||||||||
| FaxNumber: | 9155444102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2010 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | HANCOCK | ||||||||
| AuthorizedOfficialFirstName: | FLOYD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRES / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9155444100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1111896 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2885147-01 | 05 | TX | MEDICAID | TXB129022 | 01 | MEDICARE | OTHER |