Healthcare Provider Details

I. General information

NPI: 1104190347
Provider Name (Legal Business Name): SPINE AND SPORTS REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2012
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N MAIN ST
HARRISON AR
72601-3535
US

IV. Provider business mailing address

PO BOX 861
HARRISON AR
72602-0861
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-1206
  • Fax: 870-743-5974
Mailing address:
  • Phone: 870-741-1206
  • Fax: 870-743-5974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: NORMA LEE STOCKSTILL
Title or Position: OFFICE MANAGER
Credential:
Phone: 870-741-1206