Provider Demographics
NPI:1306496609
Name:POTHIREDDY, BALA NIKLESH REDDY
Entity type:Individual
Prefix:
First Name:BALA NIKLESH REDDY
Middle Name:
Last Name:POTHIREDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 GENERAL CAVAZOS BLVD
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78363-7150
Mailing Address - Country:US
Mailing Address - Phone:361-595-1661
Mailing Address - Fax:
Practice Address - Street 1:1311 GENERAL CAVAZOS BLVD
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78363-7150
Practice Address - Country:US
Practice Address - Phone:361-595-9405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1270686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist