MEDICARE: MRS. BRENDA SUE SCANTLING PT MS

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	1775	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5T191	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1932200268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRENDA SUE SCANTLING PT MS

Provider Business Mailing Address
First Line	:	PO BOX 341
Second Line	:
City	:	BONNEVILLE
State	:	AR
Zip	:	72927-0341
Country	:	US
Telephone Number	:	479-675-4918
Fax Number	:	479-474-4044

Provider Business Practice Location Address
First Line	:	4505 NORTH RUDY ROAD
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-9062
Country	:	US
Telephone Number	:	479-474-4011
Fax Number	:	479-474-4044

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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