Provider Demographics
NPI:1932131455
Name:PEAK PHYSICAL THERAPY & SPORTS MEDICINE OF WYLIE
Entity Type:Organization
Organization Name:PEAK PHYSICAL THERAPY & SPORTS MEDICINE OF WYLIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR/THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BROAD
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:972-442-5287
Mailing Address - Street 1:611 W BROWN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-5816
Mailing Address - Country:US
Mailing Address - Phone:972-442-5287
Mailing Address - Fax:972-442-3181
Practice Address - Street 1:611 W BROWN ST STE 101
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-5816
Practice Address - Country:US
Practice Address - Phone:972-442-5287
Practice Address - Fax:972-442-3181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1152490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0021MJOtherBCBS GROUP #
TXDD3715OtherMEDICARE RAILROAD GROUP #
TXDD3715OtherMEDICARE RAILROAD GROUP #