1497783427 NPI number — PHYSICIAN'S THERAPY GROUP, LLC

Table of content: SHAUNA MENKE PT (NPI 1639207830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497783427 NPI number — PHYSICIAN'S THERAPY GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN'S THERAPY GROUP, LLC
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:
1497783427
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:
704 W BEEBE CAPPS EXPY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEARCY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72143-6304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-230-9726
Provider Business Mailing Address Fax Number:
501-278-5058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1125 N COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-1908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-444-7001
Provider Business Practice Location Address Fax Number:
479-713-1603
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIMARI
Authorized Official First Name:
MOSES
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
501-278-5058

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  OTR 921 , 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)





Copyright © 2007-2024 www.npivalidator.com