Healthcare Provider Details

I. General information

NPI: 1164437646
Provider Name (Legal Business Name): SALINE COUNTY PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 FERGUSON DR
BENTON AR
72015-3512
US

IV. Provider business mailing address

1115 FERGUSON DR
BENTON AR
72015-3512
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-0639
  • Fax: 501-315-7278
Mailing address:
  • Phone: 501-315-0639
  • Fax: 501-315-7278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDALL GREEN
Title or Position: OWNER
Credential: PT
Phone: 501-315-0639