Provider Demographics
NPI:1578950333
Name:SPORTS CONCUSSION TREATMENT CENTER OF TEXAS
Entity Type:Organization
Organization Name:SPORTS CONCUSSION TREATMENT CENTER OF TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GUSTAVO
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-231-1129
Mailing Address - Street 1:2940 FM 407
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HIGHLAND VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-7045
Mailing Address - Country:US
Mailing Address - Phone:972-316-9011
Mailing Address - Fax:
Practice Address - Street 1:2940 FM 407
Practice Address - Street 2:SUITE 302
Practice Address - City:HIGHLAND VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75077-7045
Practice Address - Country:US
Practice Address - Phone:972-316-9011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1055261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty