Provider Demographics
NPI:1932291697
Name:STEPHENVILLE SPORTS REHAB & PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:STEPHENVILLE SPORTS REHAB & PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:254-965-2040
Mailing Address - Street 1:2269 NW LOOP
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401
Mailing Address - Country:US
Mailing Address - Phone:254-965-2040
Mailing Address - Fax:254-965-7394
Practice Address - Street 1:2269 NORTHWEST LOOP
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-1701
Practice Address - Country:US
Practice Address - Phone:254-965-2723
Practice Address - Fax:254-965-7394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651220000208100000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0040JBOtherBLUE CROSS BLUE SHIELD
TX108013702Medicaid
9767023OtherCIGNA
278208OtherSCOTT & WHITE HEALTH PLAN
278208OtherSCOTT & WHITE HEALTH PLAN