1578647012 NPI number — MR. ROSS M PFAFF PTA, ATC

Table of content: MR. ROSS M PFAFF PTA, ATC (NPI 1578647012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578647012 NPI number — MR. ROSS M PFAFF PTA, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PFAFF
Provider First Name:
ROSS
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PTA, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578647012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12456 GREY TWIG DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76244-5546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-965-7221
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5801 BRYANT IRVIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76132-4209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-988-6873
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  36001064A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225200000X , with the licence number: 2092898 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)