MEDICARE: SPORTS THERAPY AND REHABILITATION SERVICES

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	222Z00000X	Orthotist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0035GD	OTHER	TX	BCBS
2	686182	OTHER	TX	UNITED HEALTH CARE ACN
3	3815621	OTHER	TX	CIGNA

General Provider Information

NPI Number	:	1366517542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTS THERAPY AND REHABILITATION SERVICES

Provider Business Mailing Address
First Line	:	1555 MERRIMAC CIRCLE
Second Line	:	STE 200
City	:	FORT WORTH
State	:	TX
Zip	:	76107
Country	:	US
Telephone Number	:	817-870-4949
Fax Number	:	817-338-2940

Provider Business Practice Location Address
First Line	:	1555 MERRIMAC CIRCLE
Second Line	:	STE 200
City	:	FORT WORTH
State	:	TX
Zip	:	76107
Country	:	US
Telephone Number	:	817-870-4949
Fax Number	:	817-338-2940

Authorized Official
Title or Position	:	CO OWNER PHYSICAL THERAPIST
Name	:	MRS. KATHERINE C SAHL
Credential	:	PT
Telephone Number	:	817-249-6336

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	08/01/2007

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