Provider Demographics
NPI:1689205635
Name:DALLAS FEDERAL PHYSICAL THERAPY AND REHABILITATION LLC
Entity Type:Organization
Organization Name:DALLAS FEDERAL PHYSICAL THERAPY AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:469-965-4505
Mailing Address - Street 1:PO BOX 1347
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-1347
Mailing Address - Country:US
Mailing Address - Phone:866-400-0476
Mailing Address - Fax:972-991-9548
Practice Address - Street 1:8204 ELMBROOK DR STE 175
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-7212
Practice Address - Country:US
Practice Address - Phone:469-965-4505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty