Provider Demographics
NPI:1841740347
Name:EDGE REHABILITATION AND SPORTS THERAPY - ALLEN LLC
Entity Type:Organization
Organization Name:EDGE REHABILITATION AND SPORTS THERAPY - ALLEN LLC
Other - Org Name:EDGE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:T
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:972-529-9292
Mailing Address - Street 1:788 S. WATTERS RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4998
Mailing Address - Country:US
Mailing Address - Phone:469-270-7600
Mailing Address - Fax:469-270-7599
Practice Address - Street 1:788 S. WATTERS RD
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4998
Practice Address - Country:US
Practice Address - Phone:469-270-7600
Practice Address - Fax:469-270-7599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1139004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty