Basic Information
| Provider Information | |||||||||
| NPI: | 1871130997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOERA | ||||||||
| FirstName: | BROOKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103164844 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109164141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2019 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225100000X | 1325826 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 273955978 | 01 | TAX ID | OTHER |