Provider Demographics
NPI:1811038029
Name:SUMMIT PEAK PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SUMMIT PEAK PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:817-705-8558
Mailing Address - Street 1:166 RANCHWAY DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7864
Mailing Address - Country:US
Mailing Address - Phone:817-426-5439
Mailing Address - Fax:972-606-1637
Practice Address - Street 1:2461 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3852
Practice Address - Country:US
Practice Address - Phone:972-606-4858
Practice Address - Fax:972-606-1637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX660120001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y947OtherMEDICARE PTAN