=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447521018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL MANAGEMENT PROFESSIONALS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2012
-----------------------------------------------------
Last Update Date | 01/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 916 E HIGHWAY 377
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-1400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-573-1214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2550 BOYD AVE
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MBR
-----------------------------------------------------
Name | RICHARD SHAY SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-480-3798
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 1096931
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------