Provider Demographics
NPI:1518512888
Name:SALAZAR, JEFFRIL (PTA)
Entity Type:Individual
Prefix:
First Name:JEFFRIL
Middle Name:
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 WOOD PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2196
Mailing Address - Country:US
Mailing Address - Phone:516-232-1420
Mailing Address - Fax:
Practice Address - Street 1:6203 ALDEN BRIDGE DR
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77382-5121
Practice Address - Country:US
Practice Address - Phone:832-510-7537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2147625225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant