Healthcare Provider Details

I. General information

NPI: 1265067656
Provider Name (Legal Business Name): BLAKE PEPPER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 GOOD SAMARITAN DR
MOUNTAIN HOME AR
72653-5813
US

IV. Provider business mailing address

300 GOOD SAMARITAN DR
MOUNTAIN HOME AR
72653-5813
US

V. Phone/Fax

Practice location:
  • Phone: 870-404-7835
  • Fax:
Mailing address:
  • Phone: 870-404-7835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3914
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: