MEDICARE: SPORTHERAPY SOUTHWEST, PC

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	605100000	TX
2	261QR0400X	Rehabilitation Clinic/Center	605100000	TX
3	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	605100000	TX

General Provider Information

NPI Number	:	1801812698
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTHERAPY SOUTHWEST, PC

Provider Business Mailing Address
First Line	:	6037 HARRIS PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4103
Country	:	US
Telephone Number	:	817-370-9891
Fax Number	:	817-370-9894

Provider Business Practice Location Address
First Line	:	6037 HARRIS PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4103
Country	:	US
Telephone Number	:	817-370-9891
Fax Number	:	817-370-9894

Authorized Official
Title or Position	:	BUSINESS DIRECTOR
Name	:	MR. STEVEN B LACKEY
Credential	:
Telephone Number	:	817-370-9891

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	05/20/2014

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