=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962022970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R3 PHYSIOTHERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2020
-----------------------------------------------------
Last Update Date | 04/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11601 EMORY TRL
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76244-8805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-726-6267
-----------------------------------------------------
Fax | 682-593-3599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11601 EMORY TRL
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76244-8805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-726-6267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JASON WAYNE RACCA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-726-6267
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------