Healthcare Provider Details

I. General information

NPI: 1013531763
Provider Name (Legal Business Name): BONNIE HURST PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17430 CAMPBELL RD STE 112
DALLAS TX
75252-5297
US

IV. Provider business mailing address

5649 CHARLESTOWN DR
DALLAS TX
75230-1729
US

V. Phone/Fax

Practice location:
  • Phone: 214-628-9047
  • Fax:
Mailing address:
  • Phone: 972-979-7785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1104685
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: