Provider Demographics
NPI:1578750154
Name:TMI SPORTS THERAPY LP
Entity Type:Organization
Organization Name:TMI SPORTS THERAPY LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WABBERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:972-623-2629
Mailing Address - Street 1:2044 N HWY 360
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-1423
Mailing Address - Country:US
Mailing Address - Phone:972-623-2629
Mailing Address - Fax:972-623-2661
Practice Address - Street 1:2044 N HWY 360
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-1423
Practice Address - Country:US
Practice Address - Phone:972-623-2629
Practice Address - Fax:972-623-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1157230225100000X
TX2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T6887OtherBCBS-INDIVIDUAL #
TX0041PBOtherBCBS-GROUP#