Healthcare Provider Details

I. General information

NPI: 1568427359
Provider Name (Legal Business Name): WILLIAM GLENN LARSON LIC PHYSICAL THERAPI
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 LAKESHORE DRIVE
HOT SPRINGS AR
71913
US

IV. Provider business mailing address

284 HIDDEN VALLEY
HOT SPRINGS AR
71913
US

V. Phone/Fax

Practice location:
  • Phone: 507-760-7440
  • Fax: 501-760-7442
Mailing address:
  • Phone: 501-525-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2022
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: