Basic Information
Provider Information | |||||||||
NPI: | 1790939536 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAN MARCOS PT SPECIALISTS, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2550 HUNTER RD STE 1104 | ||||||||
Address2: |   | ||||||||
City: | SAN MARCOS | ||||||||
State: | TX | ||||||||
PostalCode: | 786665109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123965122 | ||||||||
FaxNumber: | 5123965123 | ||||||||
Practice Location | |||||||||
Address1: | 8930 FOUR WINDS DR | ||||||||
Address2: | 109 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782391970 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8885904002 | ||||||||
FaxNumber: | 2105904585 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2008 | ||||||||
LastUpdateDate: | 11/06/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAKER | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: | CHARLES | ||||||||
AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
AuthorizedOfficialTelephone: | 5123965122 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.C., P.T. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NN1001X | 5841 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | Nutrition | 225100000X | 1173060 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.