Provider Demographics
NPI:1356746978
Name:SOURCE ONE PHYSICAL THERAPY
Entity type:Organization
Organization Name:SOURCE ONE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JARROD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-577-9191
Mailing Address - Street 1:PO BOX 25006
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-2006
Mailing Address - Country:US
Mailing Address - Phone:469-658-0100
Mailing Address - Fax:469-658-0101
Practice Address - Street 1:8080 INDEPENDENCE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75025
Practice Address - Country:US
Practice Address - Phone:469-658-0100
Practice Address - Fax:469-658-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty