Provider Demographics
NPI:1922587534
Name:KONVICKA, DILLON SCOT
Entity Type:Individual
Prefix:
First Name:DILLON
Middle Name:SCOT
Last Name:KONVICKA
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 1:1004 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:YOAKUM
Mailing Address - State:TX
Mailing Address - Zip Code:77995-4703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 KAHN ST
Practice Address - Street 2:
Practice Address - City:HALLETTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77964-2177
Practice Address - Country:US
Practice Address - Phone:361-798-3606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2068048225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant