Healthcare Provider Details

I. General information

NPI: 1467817239
Provider Name (Legal Business Name): GREGORY MEYER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 T P WHITE DR
JACKSONVILLE AR
72076-2514
US

IV. Provider business mailing address

23 RED BIRD CV
CABOT AR
72023-7048
US

V. Phone/Fax

Practice location:
  • Phone: 501-241-0410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPTA1910
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: