Healthcare Provider Details

I. General information

NPI: 1902184351
Provider Name (Legal Business Name): CLAYTON COUNTS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3114 FOX RD SUITE A
JONESBORO AR
72404-9322
US

IV. Provider business mailing address

4010 BRANDYWINE DR
JONESBORO AR
72404-0720
US

V. Phone/Fax

Practice location:
  • Phone: 870-530-3693
  • Fax: 870-933-9293
Mailing address:
  • Phone: 870-530-3693
  • Fax: 870-933-9293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA2505
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: