Provider Demographics
NPI:1174066120
Name:EXCEL SPINE AND SPORTS REHAB PC
Entity type:Organization
Organization Name:EXCEL SPINE AND SPORTS REHAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:469-865-7297
Mailing Address - Street 1:3705 LAKEVIEW PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-4178
Mailing Address - Country:US
Mailing Address - Phone:469-443-0458
Mailing Address - Fax:469-573-6918
Practice Address - Street 1:3705 LAKEVIEW PKWY STE 105
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4178
Practice Address - Country:US
Practice Address - Phone:469-443-0458
Practice Address - Fax:469-573-6918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-23
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1124683261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1457461915OtherNATIONAL PROVIDER IDENTIFIER