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General NPI Number Information
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NPI Number | 1699059394
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Entity Type | Organization
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Legal Business Name | AMPIC REHAB, PLLC
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Dates
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Enumeration Date | 09/29/2011
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Last Update Date | 09/29/2011
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Provider Practice Location Address
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Address Line | 7704 SAN JACINTO PL SUITE 200
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City | PLANO
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State | TX
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Zip | 75024-3202
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Country | US
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Telephone | 214-733-7869
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Fax |
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Provider Business Mailing Address
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Address Line | 4510 DRUID LN #111
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City | DALLAS
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State | TX
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Zip | 75205-4717
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Country | US
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Telephone | 214-733-7869
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICAL THERAPIST
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Name | DR. MARK BRENNAN RUSSO
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Credential | PT, DPT
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Telephone | 214-733-7869
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1198529
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1178901
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License Number State | TX
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