Provider Demographics
NPI:1790302511
Name:DR PEPPER PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:DR PEPPER PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TALIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:806-787-7053
Mailing Address - Street 1:437 SW WILSHIRE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5300
Mailing Address - Country:US
Mailing Address - Phone:817-916-0878
Mailing Address - Fax:817-916-0879
Practice Address - Street 1:437 SW WILSHIRE BLVD STE B
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5300
Practice Address - Country:US
Practice Address - Phone:817-916-0878
Practice Address - Fax:817-916-0879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-27
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX849T45OtherBLUE CROSS BLUE SHIELD TEXAS
TX219827703Medicaid