Healthcare Provider Details

I. General information

NPI: 1710975008
Provider Name (Legal Business Name): PRESIDENTIAL MOBILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 12/18/2024
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 ROLLING HILLS DR. STE. 110
FAYETTEVILLE AR
72703
US

IV. Provider business mailing address

PO BOX 10665
FAYETTEVILLE AR
72703-0046
US

V. Phone/Fax

Practice location:
  • Phone: 479-332-4990
  • Fax: 479-332-4290
Mailing address:
  • Phone: 479-332-4990
  • Fax: 479-332-4290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: ROBIN GRIDER
Title or Position: DME MANAGER
Credential: ATP
Phone: 479-332-4990