1619152998 NPI number — REDDICK PHYSICAL THERAPY, P.A.

Table of content: SAMANTHA N BLEVINS (NPI 1730432592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619152998 NPI number — REDDICK PHYSICAL THERAPY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REDDICK PHYSICAL THERAPY, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1619152998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 VALLEY VIEW LN
Provider Second Line Business Mailing Address:
SUITE 1025
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75062-5056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-441-3046
Provider Business Mailing Address Fax Number:
214-441-3056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 VALLEY VIEW LN
Provider Second Line Business Practice Location Address:
SUITE 1025
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75062-5056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-441-3046
Provider Business Practice Location Address Fax Number:
214-441-3056
Provider Enumeration Date:
01/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
REDDICK
Authorized Official First Name:
SYBIL
Authorized Official Middle Name:
ROCHELLE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
214-441-3046

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  J9294 , 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)

  • Identifier: 8A9795 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8F7937 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0086KD . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8G1486 . This is a "MEDICARE UNSPECIFED" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8J8110 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8G1887 . This is a "MEDICARE ID UNSPECIFIED" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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