1124020979 NPI number — PHYSICAL THERAPY OF MANSFIELD,LLC

Table of content: (NPI 1124020979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124020979 NPI number — PHYSICAL THERAPY OF MANSFIELD,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL THERAPY OF MANSFIELD,LLC
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:
6
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:
1124020979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 501
Provider Second Line Business Mailing Address:
1580 HWY 287 N
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-0501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-473-4684
Provider Business Mailing Address Fax Number:
817-473-1170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1580 HIGHWAY 287 N
Provider Second Line Business Practice Location Address:
1580 HWY 287 N
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76063-7593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-473-4684
Provider Business Practice Location Address Fax Number:
817-473-1170
Provider Enumeration Date:
08/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
817-473-4684

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  658850000 , 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: 135244 . This is a "PT LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 612949000 . This is a "OWCP FED#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 604770000 . This is a "CLINIC REGISTRATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 658850000 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 752472481 . This is a "OLD TAX ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: DG4667 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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