=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730569054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCVAY PHYSICAL THERAPY & WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2015
-----------------------------------------------------
Last Update Date | 06/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1475 RICHARDSON DR STE 210
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-4659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-941-4603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1475 RICHARDSON DR STE 210
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-4659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-941-4603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD THERAPIST/OWNER
-----------------------------------------------------
Name | MILLER MCVAY
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 469-941-4603
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1183870
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------