Provider Demographics
NPI:1124020979
Name:PHYSICAL THERAPY OF MANSFIELD,LLC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY OF MANSFIELD,LLC
Other - Org Name:SUSAN G. ROBERSON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-473-4684
Mailing Address - Street 1:PO BOX 501
Mailing Address - Street 2:1580 HWY 287 N
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-0501
Mailing Address - Country:US
Mailing Address - Phone:817-473-4684
Mailing Address - Fax:817-473-1170
Practice Address - Street 1:1580 HIGHWAY 287 N
Practice Address - Street 2:1580 HWY 287 N
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7593
Practice Address - Country:US
Practice Address - Phone:817-473-4684
Practice Address - Fax:817-473-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX658850000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135244OtherPT LICENSE
TX612949000OtherOWCP FED#
TX604770000OtherCLINIC REGISTRATION
TX658850000OtherLICENSE
TX752472481OtherOLD TAX ID
TXDG4667OtherRAILROAD MEDICARE
TX00X632Medicare PIN