Provider Demographics
NPI:1497048730
Name:SOUTHLAKE SPORTS & SPINE REHAB PLLC
Entity Type:Organization
Organization Name:SOUTHLAKE SPORTS & SPINE REHAB PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT, OCS
Authorized Official - Phone:817-498-3919
Mailing Address - Street 1:1109 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5849
Mailing Address - Country:US
Mailing Address - Phone:817-498-3919
Mailing Address - Fax:817-498-7080
Practice Address - Street 1:1050 E HIGHWAY 114
Practice Address - Street 2:SUITE 110
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5253
Practice Address - Country:US
Practice Address - Phone:817-491-4775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty