Provider Demographics
NPI:1659528610
Name:PRACTIVA HEALTH LLC
Entity Type:Organization
Organization Name:PRACTIVA HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PIETER
Authorized Official - Middle Name:LAURUS
Authorized Official - Last Name:DE SMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:210-949-0070
Mailing Address - Street 1:29144 OLD FREDERICKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78015-9101
Mailing Address - Country:US
Mailing Address - Phone:210-949-0070
Mailing Address - Fax:210-949-0277
Practice Address - Street 1:5282 MEDICAL DR
Practice Address - Street 2:SUITE 205A
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4849
Practice Address - Country:US
Practice Address - Phone:210-949-0070
Practice Address - Fax:210-949-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1072643261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy