Provider Demographics
NPI:1821149733
Name:FORT WORTH REHAB GROUP
Entity Type:Organization
Organization Name:FORT WORTH REHAB GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BANION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-432-0910
Mailing Address - Street 1:3523 MCKINNEY AVE
Mailing Address - Street 2:# 246
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-1401
Mailing Address - Country:US
Mailing Address - Phone:214-432-0910
Mailing Address - Fax:
Practice Address - Street 1:3301 N MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76106-4344
Practice Address - Country:US
Practice Address - Phone:817-624-4141
Practice Address - Fax:817-624-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8454111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV07398Medicare UPIN
TX8D9992Medicare ID - Type Unspecified