Provider Demographics
NPI:1568538049
Name:9TH AVENUE PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:9TH AVENUE PHYSICAL THERAPY, PLLC
Other - Org Name:PARK PLAZA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:SOAN
Authorized Official - Last Name:MANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:409-466-7138
Mailing Address - Street 1:PO BOX 1488
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-1488
Mailing Address - Country:US
Mailing Address - Phone:409-466-7139
Mailing Address - Fax:409-729-8114
Practice Address - Street 1:8333 9TH AVE.
Practice Address - Street 2:SUITE D
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642
Practice Address - Country:US
Practice Address - Phone:409-729-8111
Practice Address - Fax:409-729-8114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1047017261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3960760OtherAETNA
TX3714404OtherCIGNA
TX98MEOtherBCBS
TX00690YMedicare ID - Type UnspecifiedGROUP NUMBER
TX8E0318Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER