Healthcare Provider Details

I. General information

NPI: 1306948807
Provider Name (Legal Business Name): MICHAEL WADE COLLINS II P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 BAY HILL DR
CONWAY AR
72034-8196
US

IV. Provider business mailing address

4410 BAY HILL DR
CONWAY AR
72034-8196
US

V. Phone/Fax

Practice location:
  • Phone: 318-680-5500
  • Fax:
Mailing address:
  • Phone: 318-680-5500
  • Fax: 318-680-5500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License NumberPT2750
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: