Provider Demographics
NPI:1225033145
Name:THE ORTHOPEDIC STORE
Entity Type:Organization
Organization Name:THE ORTHOPEDIC STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:HARIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-366-2990
Mailing Address - Street 1:PO BOX 792590
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78279-2590
Mailing Address - Country:US
Mailing Address - Phone:210-366-2990
Mailing Address - Fax:210-499-4984
Practice Address - Street 1:1211 ARION PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-2808
Practice Address - Country:US
Practice Address - Phone:210-366-2990
Practice Address - Fax:210-499-4984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX643020000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1446635-01Medicaid
TX0040GZOtherBCBS OF TEXAS-PT
TX643020000OtherTEXAS BOARD OF PHYSICAL THERAPY EXAMINERS
TX1446627-01Medicaid
TX1446627-01Medicaid
TX643020000OtherTEXAS BOARD OF PHYSICAL THERAPY EXAMINERS