Provider Demographics
NPI:1336347525
Name:PHYSICARE ANCILLARY SERVICE CORPORATION
Entity Type:Organization
Organization Name:PHYSICARE ANCILLARY SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:817-594-9200
Mailing Address - Street 1:PO BOX 2306
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-7306
Mailing Address - Country:US
Mailing Address - Phone:817-594-9200
Mailing Address - Fax:
Practice Address - Street 1:925 SANTA FE DR
Practice Address - Street 2:SUITE 111
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5866
Practice Address - Country:US
Practice Address - Phone:817-594-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26048050564251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health