Provider Demographics
NPI:1871022335
Name:MOTION CENTRIC FITNESS AND REHAB SPECIALISTS, LLC
Entity Type:Organization
Organization Name:MOTION CENTRIC FITNESS AND REHAB SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DIDLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CSCS
Authorized Official - Phone:512-817-8691
Mailing Address - Street 1:7780 OLD 195
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:TX
Mailing Address - Zip Code:76527-4543
Mailing Address - Country:US
Mailing Address - Phone:512-817-8691
Mailing Address - Fax:
Practice Address - Street 1:7780 OLD 195
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:TX
Practice Address - Zip Code:76527-4543
Practice Address - Country:US
Practice Address - Phone:512-817-8691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1239100261QP2000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy