Lake Fork Physical Therapy, PLLC
Organization Active NPI Physical Therapist · Emory, TX
NPI 1154540540 · NPPES record last updated Jul 8, 2014
Key facts
- NPI
- 1154540540
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Physical Therapist 225100000X
- License
- 1124006 (TX)
- Legal business name
- LAKE FORK PHYSICAL THERAPY, PLLC
- Practice address
- 903 East Lennon Street
Suite 101
Emory, TX 75440 - Phone
- (903) 474-9436
- NPI assigned
- Apr 24, 2007
- Organization subpart
- No
Authorized official
- Name
- Mr. Paul Bacon, L.P.T.
- Title
- Licensed Physical Therapist
- Phone
- (903) 474-9436
Practitioners 1
-
Paul Bacon, PHYSICAL THERAPIST
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070510000267 | TX | Part B Supplier - Physical/Occupational Therapy Group in Private Practice | 6406952217 |
Receives reassigned benefits from 1 practitioner Practice locations: Emory, TX |
National Provider Directory
Locations
903 E Lennon Dr
Ste 101
Emory, TX 75440
Phone (903) 474-9436
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist |
225100000X | 1124006 | TX | Yes |
Addresses
Primary practice location
903 East Lennon Street
Suite 101
Emory, TX 75440
Mailing address
903 East Lennon Street
Suite 101
Emory, TX 75440
Phone (903) 474-9436
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00X464 | Other | TX | MEDICARE GROUP |
Other providers in Emory, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.