Provider Demographics
NPI:1396730297
Name:AMISTAD PHYSICAL THERAPY CLINIC, LLC
Entity type:Organization
Organization Name:AMISTAD PHYSICAL THERAPY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALSUP
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:830-774-1556
Mailing Address - Street 1:1308 N BEDELL AVE
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-7818
Mailing Address - Country:US
Mailing Address - Phone:830-774-1556
Mailing Address - Fax:830-774-6150
Practice Address - Street 1:1308 N BEDELL AVE
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-7818
Practice Address - Country:US
Practice Address - Phone:830-774-1556
Practice Address - Fax:830-774-6150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX649830000/553250000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155663101Medicaid
TX26JBOtherBC/BS GROUP NUMBER
TX351640200OtherUS DEPT. OF LABOR GROUP #
TX155663101Medicaid