=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578381893
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IRONSIDE PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2024
-----------------------------------------------------
Last Update Date | 09/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 S NOLEN DR STE 100
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-8095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-651-5618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 TURNER RD APT 528
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-7250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GARRETT JONES
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 208-270-0325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------