Healthcare Provider Details

I. General information

NPI: 1194493767
Provider Name (Legal Business Name): AVERY HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 N DIXIELAND RD
ROGERS AR
72756-6816
US

IV. Provider business mailing address

PO BOX 130
ROGERS AR
72757-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-986-5150
  • Fax: 479-986-5191
Mailing address:
  • Phone: 479-986-5150
  • Fax: 479-986-5191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4970
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: