Provider Demographics
NPI:1154540540
Name:LAKE FORK PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:LAKE FORK PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:903-474-9436
Mailing Address - Street 1:903 EAST LENNON STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EMORY
Mailing Address - State:TX
Mailing Address - Zip Code:75440
Mailing Address - Country:US
Mailing Address - Phone:903-474-9436
Mailing Address - Fax:
Practice Address - Street 1:903 EAST LENNON STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:EMORY
Practice Address - State:TX
Practice Address - Zip Code:75440
Practice Address - Country:US
Practice Address - Phone:903-474-9436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1124006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00X464OtherMEDICARE GROUP