Provider Demographics
NPI:1538815576
Name:PHYSIOLOGIC, LLC
Entity type:Organization
Organization Name:PHYSIOLOGIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:817-366-5754
Mailing Address - Street 1:7705 BRYCE CANYON DR W
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-4313
Mailing Address - Country:US
Mailing Address - Phone:682-553-1913
Mailing Address - Fax:
Practice Address - Street 1:709 N FM 1187
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-4338
Practice Address - Country:US
Practice Address - Phone:817-366-5754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-28
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790431989Medicaid
TX1871020768Medicaid