Provider Demographics
NPI:1790847317
Name:BOUCHER, ANTHONY MANNING (MPT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MANNING
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2500
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087
Mailing Address - Country:US
Mailing Address - Phone:972-771-0999
Mailing Address - Fax:972-771-2281
Practice Address - Street 1:8885 HWY 34 SOUTH
Practice Address - Street 2:
Practice Address - City:QUINLAN
Practice Address - State:TX
Practice Address - Zip Code:75474
Practice Address - Country:US
Practice Address - Phone:903-356-4100
Practice Address - Fax:903-356-4140
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1105583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165348701Medicaid
TX456643Medicare PIN