1811038029 NPI number — SUMMIT PEAK PHYSICAL THERAPY PC

Table of content: (NPI 1811038029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811038029 NPI number — SUMMIT PEAK PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT PEAK PHYSICAL THERAPY PC
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:
1811038029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
166 RANCHWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLESON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76028-7864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-426-5439
Provider Business Mailing Address Fax Number:
972-606-1637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2461 ROBINSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75051-3852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-606-4858
Provider Business Practice Location Address Fax Number:
972-606-1637
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOSES
Authorized Official First Name:
JASON
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-705-8558

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  660120001 , 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: 00Y947 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com