Provider Demographics
NPI:1215167374
Name:PT2 SPORTS LLC
Entity type:Organization
Organization Name:PT2 SPORTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS
Authorized Official - Phone:214-695-8847
Mailing Address - Street 1:PO BOX 670846
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75367-0846
Mailing Address - Country:US
Mailing Address - Phone:214-695-8847
Mailing Address - Fax:214-239-0991
Practice Address - Street 1:1602 HART ST
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:214-695-8847
Practice Address - Fax:214-239-0991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6663400002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX823T99OtherBLUE CROSS BLUE SHIELD OF TEXAS