Provider Demographics
NPI:1023282811
Name:MEDINA VALLEY SPINE AND JOINT, LLC
Entity type:Organization
Organization Name:MEDINA VALLEY SPINE AND JOINT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:KOTHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:830-931-2211
Mailing Address - Street 1:209 US HIGHWAY 90 W
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CASTROVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78009-4540
Mailing Address - Country:US
Mailing Address - Phone:830-931-2211
Mailing Address - Fax:830-538-3778
Practice Address - Street 1:209 US HIGHWAY 90 W
Practice Address - Street 2:SUITE 2
Practice Address - City:CASTROVILLE
Practice Address - State:TX
Practice Address - Zip Code:78009-4540
Practice Address - Country:US
Practice Address - Phone:830-931-2211
Practice Address - Fax:830-538-3778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109851225X00000X
TXDC6704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty