Provider Demographics
NPI:1417189424
Name:BALANCE DIZZINESS & PHYSICAL THERAPY CLINIC, LLC
Entity Type:Organization
Organization Name:BALANCE DIZZINESS & PHYSICAL THERAPY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:409-899-1100
Mailing Address - Street 1:3560 DELAWARE ST
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3067
Mailing Address - Country:US
Mailing Address - Phone:409-899-1100
Mailing Address - Fax:409-899-1120
Practice Address - Street 1:3560 DELAWARE ST
Practice Address - Street 2:SUITE 1002
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3067
Practice Address - Country:US
Practice Address - Phone:409-899-1100
Practice Address - Fax:409-899-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-10
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1113884225100000X
TX108802225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty