Healthcare Provider Details

I. General information

NPI: 1982608550
Provider Name (Legal Business Name): BRAD STACY ALLEN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4214 98TH ST
LUBBOCK TX
79423-3957
US

IV. Provider business mailing address

5521 50TH ST APT 807
LUBBOCK TX
79414-1647
US

V. Phone/Fax

Practice location:
  • Phone: 806-712-7878
  • Fax: 806-722-7878
Mailing address:
  • Phone: 979-450-4602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1085595
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: