Healthcare Provider Details

I. General information

NPI: 1730454935
Provider Name (Legal Business Name): SPINE AND SPORTS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S BLOOMINGTON ST SUITE A
LOWELL AR
72745-9493
US

IV. Provider business mailing address

PO BOX 1938
LOWELL AR
72745-1938
US

V. Phone/Fax

Practice location:
  • Phone: 479-770-5655
  • Fax: 479-770-5656
Mailing address:
  • Phone: 479-770-5655
  • Fax: 479-770-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NORMA LEE STOCKSTILL
Title or Position: OFFICE MANAGER
Credential:
Phone: 870-280-8442