Basic Information
| Provider Information | |||||||||
| NPI: | 1568875318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARVACHO | ||||||||
| FirstName: | NICOLE | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Credential: | PT, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 NE LOOP 280 | ||||||||
| Address2: | BUSINESS TOWER 1 SUITE 200 | ||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 17480 NORTH DALLAS TOLLWAY | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146235900 | ||||||||
| FaxNumber: | 2146235901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2014 | ||||||||
| LastUpdateDate: | 06/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | 1211128 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No ID Information.