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General NPI Number Information
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NPI Number | 1245005099
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Entity Type | Individual
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Provider Name | PETER COLEMAN GRADER OTR/L
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Gender | Male
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Dates
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Enumeration Date | 11/21/2023
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Last Update Date | 11/21/2023
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Provider Practice Location Address
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Address Line | 4109 WESTRIDGE AVE
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City | FORT WORTH
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State | TX
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Zip | 76116-7403
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Country | US
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Telephone | 817-813-9431
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Fax |
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Provider Business Mailing Address
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Address Line | 417 DOVE LN
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City | FORT WORTH
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State | TX
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Zip | 76108-3793
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Country | US
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Telephone | 817-223-7734
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 102507
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 102507
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License Number State | TX
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