Provider Demographics
NPI:1932291697
Name:STEPHENVILLE SPORTS REHAB & PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:STEPHENVILLE SPORTS REHAB & PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ELMS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:817-341-3600
Mailing Address - Street 1:141 COLLEGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5653
Mailing Address - Country:US
Mailing Address - Phone:817-341-3600
Mailing Address - Fax:817-599-8181
Practice Address - Street 1:141 COLLEGE PARK DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5653
Practice Address - Country:US
Practice Address - Phone:817-341-3600
Practice Address - Fax:817-599-8181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
TX651220000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
278208OtherSCOTT & WHITE HEALTH PLAN
TX622548400OtherDEPT OF LOABOR
TX0040JBOtherBLUE CROSS BLUE SHIELD
TX108013702Medicaid
9767023OtherCIGNA