=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073403093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOREST PARK MANAGEMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2025
-----------------------------------------------------
Last Update Date | 07/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 SOUTHWEST BLVD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-9403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-307-9520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2111 FOREST PARK BLVD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76110-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-307-9520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MICHAEL MACKO
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 817-307-9520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------