Healthcare Provider Details

I. General information

NPI: 1174829683
Provider Name (Legal Business Name): VIBHA M PATEL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 40TH AVE
PINE BLUFF AR
71603-6301
US

IV. Provider business mailing address

805 SANDSTONE CIR APT 7
RUSSELLVILLE AR
72802-7109
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-8776
  • Fax:
Mailing address:
  • Phone: 479-498-2045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 2066
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: