Provider Demographics
NPI:1851917801
Name:FYZICAL CORPUS CHRISTI LLC
Entity Type:Organization
Organization Name:FYZICAL CORPUS CHRISTI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-269-0242
Mailing Address - Street 1:4510 GRAND LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5267
Mailing Address - Country:US
Mailing Address - Phone:210-269-0242
Mailing Address - Fax:
Practice Address - Street 1:3201 AIRLINE RD STE E
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-3571
Practice Address - Country:US
Practice Address - Phone:361-334-1033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1932696721Medicaid