MEDICARE: HUMAN FUNCTION AND PERFORMANCE, LLC

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1689153793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUMAN FUNCTION AND PERFORMANCE, LLC

Provider Business Mailing Address
First Line	:	1408 N RIVERFRONT BLVD # 211
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75207-3912
Country	:	US
Telephone Number	:	469-626-7254
Fax Number	:	214-237-1283

Provider Business Practice Location Address
First Line	:	136 GLASS ST # 140
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75207-6910
Country	:	US
Telephone Number	:	469-626-7254
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	JOHN EARLS
Credential	:	PT, DPT
Telephone Number	:	802-505-5013

Provider Enumeration Date	:	08/09/2018
Last Update Date	:	09/30/2019

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