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General NPI Number Information
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NPI Number | 1154540540
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Entity Type | Organization
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Legal Business Name | LAKE FORK PHYSICAL THERAPY, PLLC
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 07/08/2014
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Provider Practice Location Address
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Address Line | 903 EAST LENNON STREET SUITE 101
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City | EMORY
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State | TX
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Zip | 75440
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Country | US
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Telephone | 903-474-9436
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Fax |
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Provider Business Mailing Address
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Address Line | 903 EAST LENNON STREET SUITE 101
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City | EMORY
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State | TX
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Zip | 75440
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Country | US
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Telephone | 903-474-9436
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Fax |
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Authorized Official
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Title or Position | LICENSED PHYSICAL THERAPIST
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Name | MR. PAUL BACON
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Credential | L.P.T.
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Telephone | 903-474-9436
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1124006
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License Number State | TX
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