Provider Demographics
NPI:1710537022
Name:JAP PHYSICAL THERAPY
Entity Type:Organization
Organization Name:JAP PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:NUBEA
Authorized Official - Last Name:FOMBON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:214-718-9593
Mailing Address - Street 1:601 S GREAT SOUTHWEST PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1057
Mailing Address - Country:US
Mailing Address - Phone:214-419-2528
Mailing Address - Fax:
Practice Address - Street 1:601 S GREAT SOUTHWEST PKWY STE 106
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1057
Practice Address - Country:US
Practice Address - Phone:214-419-2528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNONEOtherNONE YET