Provider Demographics
NPI:1194858712
Name:ACTION SPORTS MEDICINE AND PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ACTION SPORTS MEDICINE AND PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:NICHOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:325-676-5633
Mailing Address - Street 1:1749 PINE ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-3043
Mailing Address - Country:US
Mailing Address - Phone:325-676-5633
Mailing Address - Fax:325-676-8831
Practice Address - Street 1:1749 PINE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-3043
Practice Address - Country:US
Practice Address - Phone:325-676-5633
Practice Address - Fax:325-676-8831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-7925-9225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0045KXOtherBLUE CROSS BLUE SHIELD
TX1706194-01Medicaid
TX1706194-01Medicaid