Provider Demographics
NPI:1235352436
Name:SOFIA WILTENS LPT
Entity Type:Organization
Organization Name:SOFIA WILTENS LPT
Other - Org Name:VERSATILE PHYSICAL THERAPY AND FITNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/LPT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SOFIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILTENS
Authorized Official - Suffix:SR
Authorized Official - Credentials:LPT
Authorized Official - Phone:512-707-8392
Mailing Address - Street 1:1221 W BEN WHITE BLVD
Mailing Address - Street 2:211A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6888
Mailing Address - Country:US
Mailing Address - Phone:512-707-8392
Mailing Address - Fax:512-707-2841
Practice Address - Street 1:1221 W BEN WHITE BLVD
Practice Address - Street 2:211A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6888
Practice Address - Country:US
Practice Address - Phone:512-707-8392
Practice Address - Fax:512-707-2841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1062495261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0009JZOtherBCBS GROUP NUMBER
TX00230XMedicare PIN