=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346642527
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL PRUITT D.P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2014
-----------------------------------------------------
Last Update Date | 09/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5501 GORDON SMITH DR STE 100
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75089-3210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-475-5122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 GARDEN DR
-----------------------------------------------------
City | SEARCY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72143-5067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-625-4816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1250380
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------