MEDICARE: HEATHER RIDENOURE PT, ATC

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	2068	AR

General Provider Information

NPI Number	:	1811526940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER RIDENOURE PT, ATC

Provider Business Mailing Address
First Line	:	5103 S GROVE DR
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-8817
Country	:	US
Telephone Number	:	479-530-8699
Fax Number	:

Provider Business Practice Location Address
First Line	:	5103 S GROVE DR
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-8817
Country	:	US
Telephone Number	:	479-530-8699
Fax Number	:

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

Provider Enumeration Date	:	04/01/2020
Last Update Date	:	04/01/2020

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