Provider Demographics
NPI:1417079245
Name:BRAZOS VALLEY P.T., P.C.
Entity Type:Organization
Organization Name:BRAZOS VALLEY P.T., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:979-846-2878
Mailing Address - Street 1:1716 BRIARCREST DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2763
Mailing Address - Country:US
Mailing Address - Phone:979-846-2878
Mailing Address - Fax:979-846-2877
Practice Address - Street 1:1716 BRIARCREST DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2763
Practice Address - Country:US
Practice Address - Phone:979-846-2878
Practice Address - Fax:979-846-2877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0041JZOtherBCBSGROUP OUTPATIENT P.T.
TX8T1220OtherFEDERAL BCBS P.T.
TX8T1220OtherFEDERAL BCBS P.T.