Healthcare Provider Details

I. General information

NPI: 1609847847
Provider Name (Legal Business Name): BARRON TRACY SOUTH MS, PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E DOUBLE EAGLE PL
FAYETTEVILLE AR
72701-7143
US

IV. Provider business mailing address

505 E DOUBLE EAGLE PL
FAYETTEVILLE AR
72701-7143
US

V. Phone/Fax

Practice location:
  • Phone: 479-856-6571
  • Fax: 479-856-6571
Mailing address:
  • Phone: 479-856-6571
  • Fax: 479-856-6571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberC22172
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 1781
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: