Provider Demographics
NPI:1588703557
Name:LAKE WHITNEY PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:LAKE WHITNEY PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:254-694-6831
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-0068
Mailing Address - Country:US
Mailing Address - Phone:254-694-6831
Mailing Address - Fax:
Practice Address - Street 1:204 EAST JEFFERSON
Practice Address - Street 2:
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692
Practice Address - Country:US
Practice Address - Phone:254-694-6831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161075001Medicaid
TX161075001Medicaid