Provider Demographics
NPI:1376579797
Name:TILLMAN PHYSICAL THERAPY & SPORTS TRAINING CENTER, INC
Entity Type:Organization
Organization Name:TILLMAN PHYSICAL THERAPY & SPORTS TRAINING CENTER, INC
Other - Org Name:TILLMAN PHYSICAL THERAPY & SPORTS TRAINING CENTER, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYICAL THERAPIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, CSCS, CERT MDT
Authorized Official - Phone:512-331-6200
Mailing Address - Street 1:2519 S LAKELINE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2964
Mailing Address - Country:US
Mailing Address - Phone:512-331-6200
Mailing Address - Fax:512-331-6384
Practice Address - Street 1:2519 S LAKELINE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2964
Practice Address - Country:US
Practice Address - Phone:512-331-6200
Practice Address - Fax:512-331-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX554280000261Q00000X
TX644350000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153870401Medicaid
TX153870401Medicaid
TXX67500Medicare UPIN