Healthcare Provider Details

I. General information

NPI: 1265737548
Provider Name (Legal Business Name): PROFESSIONAL FOR AGILITY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S LINCOLN ST STE D
LOWELL AR
72745-9782
US

IV. Provider business mailing address

PO BOX 861
HARRISON AR
72602-0861
US

V. Phone/Fax

Practice location:
  • Phone: 870-704-9800
  • Fax: 479-770-5656
Mailing address:
  • Phone: 870-704-9800
  • Fax: 479-770-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ANGELILA M BEJERANO
Title or Position: ADMINISTRATIVE OFFICER
Credential:
Phone: 870-704-9800