Provider Demographics
NPI:1861764722
Name:EASTSIDE PHYSIOTHERAPY CLINIC
Entity type:Organization
Organization Name:EASTSIDE PHYSIOTHERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-842-0504
Mailing Address - Street 1:1721 N LEE TREVINO DR STE B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4564
Mailing Address - Country:US
Mailing Address - Phone:915-590-1910
Mailing Address - Fax:915-225-6422
Practice Address - Street 1:1721 N LEE TREVINO DR STE B
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4564
Practice Address - Country:US
Practice Address - Phone:915-590-1910
Practice Address - Fax:915-225-6422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1147100261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2802654-01Medicaid
TXP00194843OtherRAILROAD MEDICARE PART B
TX8D3234Medicare PIN
TXP00194843OtherRAILROAD MEDICARE PART B