Healthcare Provider Details

I. General information

NPI: 1275068314
Provider Name (Legal Business Name): METROPLEX INTEGRATIVE REHABILITATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5703 WESTCREEK DR
FORT WORTH TX
76133-3301
US

IV. Provider business mailing address

5703 WESTCREEK DR
FORT WORTH TX
76133-3301
US

V. Phone/Fax

Practice location:
  • Phone: 817-921-3000
  • Fax: 817-921-3001
Mailing address:
  • Phone: 817-921-3000
  • Fax: 817-921-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number69237
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberJ6589
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1068195
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License NumberAP133741
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateTX

VIII. Authorized Official

Name: TERESA MARTIN
Title or Position: CHIEF ADMINISTRATION OFFICER
Credential:
Phone: 817-921-3000