Healthcare Provider Details

I. General information

NPI: 1396299210
Provider Name (Legal Business Name): SPENCER CHURCH PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 23RD ST
CANYON TX
79015-4645
US

IV. Provider business mailing address

907 23RD ST
CANYON TX
79015-4645
US

V. Phone/Fax

Practice location:
  • Phone: 806-655-6824
  • Fax: 806-655-6823
Mailing address:
  • Phone: 806-655-6824
  • Fax: 806-655-6823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1280486
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: