Provider Demographics
NPI:1669921433
Name:SPORTS, PHYSICIANS, ORTHOPEDICS, AND REHABILITATION OF TEXAS
Entity type:Organization
Organization Name:SPORTS, PHYSICIANS, ORTHOPEDICS, AND REHABILITATION OF TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CHERRIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-850-0203
Mailing Address - Street 1:19200 PRESTON RD
Mailing Address - Street 2:STE 120
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-2450
Mailing Address - Country:US
Mailing Address - Phone:469-200-2832
Mailing Address - Fax:469-269-1074
Practice Address - Street 1:19200 PRESTON RD
Practice Address - Street 2:STE 120
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-2450
Practice Address - Country:US
Practice Address - Phone:469-200-2832
Practice Address - Fax:469-269-1074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX425791ZQABMedicare UPIN