Healthcare Provider Details

I. General information

NPI: 1538176268
Provider Name (Legal Business Name): ERICSON SARIEGO BACSA PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 S CARAWAY RD SUITE B2
JONESBORO AR
72401-7304
US

IV. Provider business mailing address

2701 S CARAWAY RD SUITE B2
JONESBORO AR
72401-7304
US

V. Phone/Fax

Practice location:
  • Phone: 870-919-4097
  • Fax: 870-910-0245
Mailing address:
  • Phone: 870-919-4097
  • Fax: 870-910-0245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 1409
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: