Healthcare Provider Details

I. General information

NPI: 1043665367
Provider Name (Legal Business Name): KNEAD PHYSICAL MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4944 PRESTON RD STE 100A
FRISCO TX
75034-8597
US

IV. Provider business mailing address

4944 PRESTON RD STE 100A
FRISCO TX
75034-8597
US

V. Phone/Fax

Practice location:
  • Phone: 469-304-3443
  • Fax:
Mailing address:
  • Phone: 469-304-3443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MISS CHRISTINA PONCE DE LEON
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 214-448-1066