Healthcare Provider Details

I. General information

NPI: 1740514058
Provider Name (Legal Business Name): KENNETH G HOLDER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 10/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HOUSTON AVE SUITE C
PERRYVILLE AR
72126-9451
US

IV. Provider business mailing address

PO BOX 11226
CONWAY AR
72034-0022
US

V. Phone/Fax

Practice location:
  • Phone: 501-889-1900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 3185
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: