Provider Demographics
NPI:1881604429
Name:TOTAL RECOVERY PHYSICAL MODALITY
Entity type:Organization
Organization Name:TOTAL RECOVERY PHYSICAL MODALITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-275-5620
Mailing Address - Street 1:PO BOX 271297
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227
Mailing Address - Country:US
Mailing Address - Phone:214-325-9508
Mailing Address - Fax:214-325-9508
Practice Address - Street 1:1100 N UNIVERSITY
Practice Address - Street 2:#240
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207
Practice Address - Country:US
Practice Address - Phone:501-614-9774
Practice Address - Fax:501-614-0789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F485Medicare PIN