Provider Demographics
NPI:1114507852
Name:NORTHWEST PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:NORTHWEST PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:254-592-0418
Mailing Address - Street 1:133 SINGLE TREE RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-1850
Mailing Address - Country:US
Mailing Address - Phone:254-592-0418
Mailing Address - Fax:
Practice Address - Street 1:408 CENTRAL DR
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3140
Practice Address - Country:US
Practice Address - Phone:817-444-8827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-08
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty