Provider Demographics
NPI:1699059394
Name:AMPIC REHAB, PLLC
Entity type:Organization
Organization Name:AMPIC REHAB, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:BRENNAN
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:214-733-7869
Mailing Address - Street 1:4510 DRUID LN
Mailing Address - Street 2:#111
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-4717
Mailing Address - Country:US
Mailing Address - Phone:214-733-7869
Mailing Address - Fax:
Practice Address - Street 1:7704 SAN JACINTO PL
Practice Address - Street 2:SUITE 200
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3202
Practice Address - Country:US
Practice Address - Phone:214-733-7869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1178901225100000X
TX1198529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty