1538573746 NPI number — IDEAL PHYSICAL THERAPY OF TEXAS LLC

Table of content: (NPI 1538573746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538573746 NPI number — IDEAL PHYSICAL THERAPY OF TEXAS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDEAL PHYSICAL THERAPY OF TEXAS 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:
1538573746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2222
Provider Business Mailing Address Fax Number:
630-759-9510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4709 W PARKER RD STE 460
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-3369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-979-6577
Provider Business Practice Location Address Fax Number:
972-979-3369
Provider Enumeration Date:
06/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MEYER
Authorized Official First Name:
WADE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VP CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
630-296-2223

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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