Provider Demographics
NPI:1487974317
Name:COUNTRY OUTPATIENT PHYSICAL THERAPY
Entity type:Organization
Organization Name:COUNTRY OUTPATIENT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN, ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:325-347-4762
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:205 E. COLLEGE ST
Mailing Address - City:MASON
Mailing Address - State:TX
Mailing Address - Zip Code:76856
Mailing Address - Country:US
Mailing Address - Phone:325-347-9600
Mailing Address - Fax:325-347-9700
Practice Address - Street 1:205 E. COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:TX
Practice Address - Zip Code:76856
Practice Address - Country:US
Practice Address - Phone:325-347-9600
Practice Address - Fax:325-347-9700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX668460000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy