Provider Demographics
NPI:1639228844
Name:GLEN ROSE PHYSICAL THERAPY AND SPORTS REHAB, P.C.
Entity Type:Organization
Organization Name:GLEN ROSE PHYSICAL THERAPY AND SPORTS REHAB, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:254-898-2121
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043-0292
Mailing Address - Country:US
Mailing Address - Phone:254-898-2121
Mailing Address - Fax:254-898-1616
Practice Address - Street 1:1005 NE BIG BEND TRL
Practice Address - Street 2:SUITE 3
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043-4942
Practice Address - Country:US
Practice Address - Phone:254-898-2121
Practice Address - Fax:254-898-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1078459225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0015NNOtherBCBS
TX181331301Medicaid
TX181331301Medicaid