Provider Demographics
NPI:1730416181
Name:LAGO VISTA PHYSICAL THERAPY
Entity type:Organization
Organization Name:LAGO VISTA PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:COLDICOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:512-267-5400
Mailing Address - Street 1:PO BOX 4649
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645
Mailing Address - Country:US
Mailing Address - Phone:512-267-5400
Mailing Address - Fax:512-267-5700
Practice Address - Street 1:5802 THUNDERBIRD ST.
Practice Address - Street 2:SUITE A
Practice Address - City:LAGO VISTA
Practice Address - State:TX
Practice Address - Zip Code:78645
Practice Address - Country:US
Practice Address - Phone:512-267-5400
Practice Address - Fax:512-267-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1182499225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201463102Medicaid
TX653086Medicare PIN