1023045705 NPI number — PROGRESSIVE PHYSICAL THERAPY

Table of content: (NPI 1023045705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023045705 NPI number — PROGRESSIVE PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE PHYSICAL THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023045705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 489
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72115-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-753-5189
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 W PERSHING BLVD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72114-2147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-753-5189
Provider Business Practice Location Address Fax Number:
501-753-0255
Provider Enumeration Date:
06/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCDONALD
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER/ PHYSICAL THERAPIST
Authorized Official Telephone Number:
501-753-5189

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1073 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 1424 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)