Provider Demographics
NPI:1679667695
Name:WILCO THERANET, LLC
Entity Type:Organization
Organization Name:WILCO THERANET, LLC
Other - Org Name:PHYSICAL THERAPY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PT DIRECTOR / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:936-294-0283
Mailing Address - Street 1:127 MEDICAL PARK LN
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-4972
Mailing Address - Country:US
Mailing Address - Phone:936-294-0283
Mailing Address - Fax:936-294-9878
Practice Address - Street 1:127 MEDICAL PARK LN
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4972
Practice Address - Country:US
Practice Address - Phone:936-294-0283
Practice Address - Fax:936-294-9878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX640210000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85643TOtherBCBS PROVIDER NUMBER
TX152359901Medicaid
TX456814Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER