Provider Demographics
NPI:1649384397
Name:VANGUARD PHYSICAL THERAPY
Entity Type:Organization
Organization Name:VANGUARD PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-485-2300
Mailing Address - Street 1:PO BOX 2067
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-2067
Mailing Address - Country:US
Mailing Address - Phone:817-485-2300
Mailing Address - Fax:817-485-2356
Practice Address - Street 1:2318 50TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-2502
Practice Address - Country:US
Practice Address - Phone:806-748-6407
Practice Address - Fax:806-687-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1135481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00768WMedicare ID - Type Unspecified