Provider Demographics
NPI:1396909164
Name:W.G. WALDO GUTIERREZ PHYSICAL THERAPY INC.
Entity type:Organization
Organization Name:W.G. WALDO GUTIERREZ PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:361-854-9741
Mailing Address - Street 1:3462 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1720
Mailing Address - Country:US
Mailing Address - Phone:361-854-9741
Mailing Address - Fax:361-854-9742
Practice Address - Street 1:3462 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1720
Practice Address - Country:US
Practice Address - Phone:361-854-9741
Practice Address - Fax:361-854-9742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX627560000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00336Medicare UPIN
TX650566Medicare PIN