Healthcare Provider Details

I. General information

NPI: 1184982894
Provider Name (Legal Business Name): PHYSICAL THERAPY ADVANTAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 DUCLAIR CT
LITTLE ROCK AR
72223-9570
US

IV. Provider business mailing address

52 DUCLAIR CT
LITTLE ROCK AR
72223-9570
US

V. Phone/Fax

Practice location:
  • Phone: 501-519-0144
  • Fax:
Mailing address:
  • Phone: 501-519-0144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number1240
License Number StateAR

VIII. Authorized Official

Name: MRS. KELLEY GLENN
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 501-519-0144