Healthcare Provider Details

I. General information

NPI: 1174777874
Provider Name (Legal Business Name): PHYSICAL MEDICINE & REHABILITATION ASSOCIATES OF NW AR PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 S 54TH ST
ROGERS AR
72758-8196
US

IV. Provider business mailing address

2054 S 54TH ST
ROGERS AR
72758-8196
US

V. Phone/Fax

Practice location:
  • Phone: 479-246-9002
  • Fax: 479-246-9005
Mailing address:
  • Phone: 479-246-9002
  • Fax: 479-246-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberMC-1930
License Number StateAR

VIII. Authorized Official

Name: DR. BORIAN B MATINCHEV
Title or Position: PRESIDENT
Credential: M.D.
Phone: 479-246-9002