Healthcare Provider Details

I. General information

NPI: 1063375111
Provider Name (Legal Business Name): REFORM REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8628 ANGEL GARDENS DR
FORT WORTH TX
76179-3144
US

IV. Provider business mailing address

8628 ANGEL GARDENS DR
FORT WORTH TX
76179-3144
US

V. Phone/Fax

Practice location:
  • Phone: 318-452-4514
  • Fax:
Mailing address:
  • Phone: 318-452-4514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: TYLER MICHOT
Title or Position: DOCTOR OF PHYSICAL THERAPY
Credential: DPT, PT
Phone: 318-452-4514