Provider Demographics
NPI:1861200073
Name:LYMPHEDEMA CLINIX TEXAS LLC
Entity type:Organization
Organization Name:LYMPHEDEMA CLINIX TEXAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:HOLMGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-243-7333
Mailing Address - Street 1:39 PIER PL
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-4918
Mailing Address - Country:US
Mailing Address - Phone:801-243-7333
Mailing Address - Fax:
Practice Address - Street 1:2128 BABCOCK RD
Practice Address - Street 2:BLDG 2 SUITE A
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-201-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty