Basic Information
| Provider Information | |||||||||
| NPI: | 1194858712 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACTION SPORTS MEDICINE AND PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1749 PINE ST | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796013043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256765633 | ||||||||
| FaxNumber: | 3256768831 | ||||||||
| Practice Location | |||||||||
| Address1: | 1749 PINE ST | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796013043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256765633 | ||||||||
| FaxNumber: | 3256768831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLLS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | BRADLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | THERAPIST IN CHARGE | ||||||||
| AuthorizedOfficialTelephone: | 3256765633 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHYSICAL THERAPIST | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1-7925-9 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0045KX | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 1706194-01 | 05 | TX | MEDICAID |