Provider Demographics
NPI:1619261757
Name:SPINE WORKS THERAPY-SOUTHLAKE, P.L.L.C.
Entity Type:Organization
Organization Name:SPINE WORKS THERAPY-SOUTHLAKE, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:B
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-616-0700
Mailing Address - Street 1:1001 WEST SOUTHLAKE BLVD.
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-310-0421
Mailing Address - Fax:817-310-5870
Practice Address - Street 1:1001 W SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6010
Practice Address - Country:US
Practice Address - Phone:817-310-0421
Practice Address - Fax:817-310-5870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5053261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center