MEDICARE: DERICK RAY HAMPEL PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	3543	AR

General Provider Information

NPI Number	:	1013261528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERICK RAY HAMPEL PT, DPT

Provider Business Mailing Address
First Line	:	1314 VANDERBUILT DR
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-9563
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 MCNEIL ST
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72015-3345
Country	:	US
Telephone Number	:	501-315-0984
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2012
Last Update Date	:	11/06/2012

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