Provider Demographics
NPI:1912398348
Name:OBACH PHYSICAL THERAPY CLINIC LLC
Entity Type:Organization
Organization Name:OBACH PHYSICAL THERAPY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-300-0234
Mailing Address - Street 1:4882 HIGHTECH DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-2613
Mailing Address - Country:US
Mailing Address - Phone:903-300-0234
Mailing Address - Fax:903-630-9999
Practice Address - Street 1:200 COUNTY ROAD 3801
Practice Address - Street 2:
Practice Address - City:BULLARD
Practice Address - State:TX
Practice Address - Zip Code:75757
Practice Address - Country:US
Practice Address - Phone:903-894-4633
Practice Address - Fax:903-894-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-06
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1059236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1059236OtherLICENSE NO.
TX1063700110OtherNPI
TXTXB134151OtherMEDICARE NO.