Healthcare Provider Details

I. General information

NPI: 1083864649
Provider Name (Legal Business Name): IDUMANGE T. IDUMANGE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W PERSHING BLVD STE D
N LITTLE ROCK AR
72114-2157
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 501-812-4970
  • Fax: 501-812-4972
Mailing address:
  • Phone: 8-824-4094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1965
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: