Provider Demographics
NPI:1881232569
Name:LIM, THEODORE
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:LIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4603 CAYMEN PL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-3730
Mailing Address - Country:US
Mailing Address - Phone:562-676-5501
Mailing Address - Fax:
Practice Address - Street 1:4603 CAYMEN PL
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-3730
Practice Address - Country:US
Practice Address - Phone:562-676-5501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13264473225100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty