Healthcare Provider Details

I. General information

NPI: 1104432327
Provider Name (Legal Business Name): SANTIAGO USCOCOVICH PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N PRICKETT RD STE 2
BRYANT AR
72022-7511
US

IV. Provider business mailing address

PO BOX 1419
ALEXANDER AR
72002-3419
US

V. Phone/Fax

Practice location:
  • Phone: 501-213-0594
  • Fax: 844-272-0941
Mailing address:
  • Phone: 501-213-0594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4576
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: