Provider Demographics
NPI:1609873439
Name:ODESSA PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:ODESSA PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:FEELER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:432-366-9541
Mailing Address - Street 1:4407 N GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5311
Mailing Address - Country:US
Mailing Address - Phone:432-366-9541
Mailing Address - Fax:432-366-1951
Practice Address - Street 1:4407 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5311
Practice Address - Country:US
Practice Address - Phone:432-366-9541
Practice Address - Fax:432-366-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00633VMedicare ID - Type Unspecified