Provider Demographics
NPI:1164609186
Name:IOWA PARK PHYSICAL THERAPY
Entity Type:Organization
Organization Name:IOWA PARK PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:BLACKERBY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:940-592-5900
Mailing Address - Street 1:620 WEST BANK
Mailing Address - Street 2:
Mailing Address - City:IOWA PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76367
Mailing Address - Country:US
Mailing Address - Phone:940-592-5900
Mailing Address - Fax:940-592-5969
Practice Address - Street 1:620 WEST BANK STREET
Practice Address - Street 2:
Practice Address - City:IOWA PARK
Practice Address - State:TX
Practice Address - Zip Code:76367
Practice Address - Country:US
Practice Address - Phone:940-592-5900
Practice Address - Fax:940-592-5969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1065332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1689679466OtherPROVIDER NPI
TX1689679466OtherPROVIDER NPI