Healthcare Provider Details

I. General information

NPI: 1578225892
Provider Name (Legal Business Name): BODY AND SPORT DFW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 SAGEBRUSH DR STE 104
FLOWER MOUND TX
75028-2744
US

IV. Provider business mailing address

2201 LONG PRAIRIE RD STE 107-845
FLOWER MOUND TX
75022-4832
US

V. Phone/Fax

Practice location:
  • Phone: 972-899-8002
  • Fax: 972-899-8003
Mailing address:
  • Phone: 972-899-8002
  • Fax: 972-899-8003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DEREK PHILLIPS
Title or Position: OFFICE MANAGER
Credential:
Phone: 972-899-8002