1760705511 NPI number — MR. MARTIN RUBEN BROYLES P.T.

Table of content: MR. MARTIN RUBEN BROYLES P.T. (NPI 1760705511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760705511 NPI number — MR. MARTIN RUBEN BROYLES P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROYLES
Provider First Name:
MARTIN
Provider Middle Name:
RUBEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

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:
1760705511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 S MAIN ST UNIT 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401-2908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3114 FOX ROAD
Provider Second Line Business Practice Location Address:
SUITE A HADLEY PEDIATRIC PHYSICAL THERAPY, PLLC,
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-933-9294
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3237 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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