1790727105 NPI number — GAYLE QUATTLEBAUM P.T.

Table of content: GAYLE QUATTLEBAUM P.T. (NPI 1790727105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790727105 NPI number — GAYLE QUATTLEBAUM P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUATTLEBAUM
Provider First Name:
GAYLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

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:
1790727105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 JACKSON STEPHENS DRIVE UAMS MAILBOX #626
Provider Second Line Business Mailing Address:
UNIVERSITY REHAB, GROUND FLOOR
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72205-7199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-661-7955
Provider Business Mailing Address Fax Number:
501-661-7961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 JACKSON STEPHENS DRIVE
Provider Second Line Business Practice Location Address:
UAMS-UNIVERSITY REHAB, GROUND FLOOR
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205-7199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-227-9920
Provider Business Practice Location Address Fax Number:
501-227-5223
Provider Enumeration Date:
06/11/2006

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:  PT497 , 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)