Provider Demographics
NPI:1578579827
Name:EAGLE PASS THERAPY CLINIC PC
Entity Type:Organization
Organization Name:EAGLE PASS THERAPY CLINIC PC
Other - Org Name:BACK TO ACTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:TICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-428-8951
Mailing Address - Street 1:PO BOX 532127
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78553
Mailing Address - Country:US
Mailing Address - Phone:956-428-8951
Mailing Address - Fax:956-428-0232
Practice Address - Street 1:1000 CROWN RIDGE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852
Practice Address - Country:US
Practice Address - Phone:830-757-2497
Practice Address - Fax:830-757-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
86MROtherBCBS
00441ZMedicare ID - Type Unspecified