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Organization
LAKE FORK PHYSICAL THERAPY, PLLC
Active
Organization
LAKE FORK PHYSICAL THERAPY, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PAUL BACON L.P.T. (LICENSED PHYSICAL THERAPIST)
(903) 474-9436
Entity
Organization
Contact information
Practice address
903 EAST LENNON STREET, SUITE 101, EMORY, TX 75440
(903) 474-9436
Mailing address
903 EAST LENNON STREET, SUITE 101, EMORY, TX 75440
(903) 474-9436
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
1124006
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00X464
MEDICARE GROUP
TX
Enumeration date
04/24/2007
Last updated
07/08/2014
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