Provider Demographics
NPI:1295853836
Name:PARADIGM PHYSICAL THERAPY & SPORTS SCIENCE CENTER
Entity Type:Organization
Organization Name:PARADIGM PHYSICAL THERAPY & SPORTS SCIENCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST,OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DSC, OCS, CHT
Authorized Official - Phone:432-580-3300
Mailing Address - Street 1:701 N GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4504
Mailing Address - Country:US
Mailing Address - Phone:432-580-3300
Mailing Address - Fax:432-580-0505
Practice Address - Street 1:701 N GRANT AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4504
Practice Address - Country:US
Practice Address - Phone:432-580-3300
Practice Address - Fax:432-580-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1072692225100000X
TX613030000261QR0401X
TX0039729332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)Group - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0060DLOtherBCBS
TX021716801OtherMEDICAID (SECONDARY)
TX144906802OtherMEDICAID DME
TX456783OtherMEDICARE
TX062884401OtherMEDICAID (PRIMARY)
TX144906801OtherMEDICAID DME
TX144906801OtherMEDICAID DME
TX1239800003Medicare NSC