Healthcare Provider Details

I. General information

NPI: 1205741311
Provider Name (Legal Business Name): BRIAN BANDELOW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N COLLEGE ST
MOUNTAIN HOME AR
72653-3653
US

IV. Provider business mailing address

201 N COLLEGE ST
MOUNTAIN HOME AR
72653-3653
US

V. Phone/Fax

Practice location:
  • Phone: 870-701-5089
  • Fax: 870-277-0896
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4248
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: