MEDICARE: PETER BLACKWELL BENTZ P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1023109	TX

General Provider Information

NPI Number	:	1053429753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER BLACKWELL BENTZ P.T.

Provider Business Mailing Address
First Line	:	1109 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4102
Country	:	US
Telephone Number	:	817-338-4220
Fax Number	:	817-338-1639

Provider Business Practice Location Address
First Line	:	1109 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4102
Country	:	US
Telephone Number	:	817-338-4220
Fax Number	:	817-338-1639

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	07/23/2008

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