Provider Demographics
NPI:1952633711
Name:SPACE CITY PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SPACE CITY PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-316-7160
Mailing Address - Street 1:17448 HIGHWAY 3, #130
Mailing Address - Street 2:P. O. BOX 58086
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-8086
Mailing Address - Country:US
Mailing Address - Phone:281-316-7160
Mailing Address - Fax:281-316-7165
Practice Address - Street 1:17448 HIGHWAY 3
Practice Address - Street 2:SUITE 130
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4197
Practice Address - Country:US
Practice Address - Phone:281-316-7160
Practice Address - Fax:281-316-7165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty