=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225544083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISTA REHAB PARTNERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2017
-----------------------------------------------------
Last Update Date | 08/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3059 CHAMPIONS WAY STE 400
-----------------------------------------------------
City | MELISSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-885-8671
-----------------------------------------------------
Fax | 469-749-7485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 ELDORADO PKWY # 10220MEL
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-6510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-885-8671
-----------------------------------------------------
Fax | 469-749-7485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | ROBERT PACE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-804-1712
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------