Healthcare Provider Details

I. General information

NPI: 1902201411
Provider Name (Legal Business Name): CHARLES LINDLEY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 DETROIT AVE
DANVILLE AR
72833-9607
US

IV. Provider business mailing address

1334 LOWDER RD
BOONEVILLE AR
72927-6938
US

V. Phone/Fax

Practice location:
  • Phone: 479-495-6252
  • Fax: 479-495-6336
Mailing address:
  • Phone: 479-495-6252
  • Fax: 479-495-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 2627
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: