Provider Demographics
NPI:1073776159
Name:B. WELL PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:B. WELL PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIKES
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:817-737-0006
Mailing Address - Street 1:6913 CAMP BOWIE BLVD
Mailing Address - Street 2:#107
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-7163
Mailing Address - Country:US
Mailing Address - Phone:817-737-0006
Mailing Address - Fax:
Practice Address - Street 1:6913 CAMP BOWIE BLVD
Practice Address - Street 2:#107
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-7163
Practice Address - Country:US
Practice Address - Phone:817-737-0006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1098580261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPTAN 0A3190Medicare PIN