Healthcare Provider Details

I. General information

NPI: 1891836516
Provider Name (Legal Business Name): PHILLIP DEWAYNE BASS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3013 TWILIGHT COVE
BRYANT AR
72022
US

IV. Provider business mailing address

3013 TWILIGHT COVE
BRYANT AR
72022
US

V. Phone/Fax

Practice location:
  • Phone: 501-258-7568
  • Fax:
Mailing address:
  • Phone: 501-258-7568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT769
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: