Healthcare Provider Details

I. General information

NPI: 1386864791
Provider Name (Legal Business Name): SAMANTHA DAWN ASHFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 S DRIVE
MOUNT IDA AR
71957
US

IV. Provider business mailing address

PO BOX 2511
WALDRON AR
72958-2511
US

V. Phone/Fax

Practice location:
  • Phone: 870-867-2584
  • Fax:
Mailing address:
  • Phone: 479-637-5368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 2084
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: