MEDICARE: LIBBEY MEMORIAL PHYSICAL MEDICINE CENTER, INC.

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	409	AR

General Provider Information

NPI Number	:	1356654362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBBEY MEMORIAL PHYSICAL MEDICINE CENTER, INC.

Provider Business Mailing Address
First Line	:	389 LAKE HAMILTON DR
Second Line	:	A7
City	:	HOT SPRINGS
State	:	AR
Zip	:	71913-6899
Country	:	US
Telephone Number	:	501-620-9812
Fax Number	:	501-545-4891

Provider Business Practice Location Address
First Line	:	389 LAKE HAMILTON DR
Second Line	:	A7
City	:	HOT SPRINGS
State	:	AR
Zip	:	71913-6899
Country	:	US
Telephone Number	:	501-620-9812
Fax Number	:	501-545-4891

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MR. DEWEY W. CROW
Credential	:	PT
Telephone Number	:	501-620-9812

Provider Enumeration Date	:	07/19/2010
Last Update Date	:	01/08/2014

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