MEDICARE: MR. WILLIAM ALLEN CHURCH PHYSICAL THERAPIST

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	1159090	TX

General Provider Information

NPI Number	:	1396067351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM ALLEN CHURCH PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	1555 MERRIMAC CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6530
Country	:	US
Telephone Number	:	817-870-4949
Fax Number	:	817-338-2940

Provider Business Practice Location Address
First Line	:	1555 MERRIMAC CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6530
Country	:	US
Telephone Number	:	817-870-4949
Fax Number	:	817-338-2940

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

Provider Enumeration Date	:	02/18/2010
Last Update Date	:	02/18/2010

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