Basic Information
| Provider Information | |||||||||
| NPI: | 1750309720 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COPPELL SPINE & SPORTS REHAB LIMITED PARTNERSHIP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHLAKE PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 E SOUTHLAKE BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760926377 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 731 EAST SOUTHLAKE BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760926380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174428600 | ||||||||
| FaxNumber: | 8174428603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BINSTEIN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7132977000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COPPELL SPINE & SPORTS REHAB LIMITED PARTNERSHIP | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | JD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.