Provider Demographics
NPI:1629356761
Name:TX770911-002, LLC
Entity Type:Organization
Organization Name:TX770911-002, LLC
Other - Org Name:LEGEND PHYSICAL THERAPY - CLEARLAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:TOMERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-564-0100
Mailing Address - Street 1:608 SANDAU RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4131
Mailing Address - Country:US
Mailing Address - Phone:210-564-0100
Mailing Address - Fax:210-564-0157
Practice Address - Street 1:1117 CLEAR LK CTY BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77062-8102
Practice Address - Country:US
Practice Address - Phone:281-401-9789
Practice Address - Fax:281-401-9779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1275111N00000X
TX1190830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty