MEDICARE: DIANE MCKIE PTA

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	225200000X	Physical Therapy Assistant	2060186	TX

General Provider Information

NPI Number	:	1477706018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE MCKIE PTA

Provider Business Mailing Address
First Line	:	3107 W CAMP WISDOM RD STE 131
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75237-2600
Country	:	US
Telephone Number	:	214-339-4533
Fax Number	:

Provider Business Practice Location Address
First Line	:	3107 W CAMP WISDOM RD STE 131
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75237-2600
Country	:	US
Telephone Number	:	214-339-4533
Fax Number	:

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

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	10/28/2008

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