Basic Information
| Provider Information | |||||||||
| NPI: | 1245273473 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THERAWORKS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SELECT PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4714 GETTYSBURG RD | ||||||||
| Address2: | LEGAL DEPT | ||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179721100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 605 ROCKMEAD DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KINGWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813489588 | ||||||||
| FaxNumber: | 2813482150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 12/05/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TARVIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7179721100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 651100000 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 550440000 | 01 | TX | STATE OT FACILITY NUMBER | OTHER | 651100000 | 01 | TX | STATE PT FACILITY NUMBER | OTHER |