Healthcare Provider Details

I. General information

NPI: 1386278836
Provider Name (Legal Business Name): KOBY KEITH HARTIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W BEEBE CAPPS EXPY
SEARCY AR
72143-6353
US

IV. Provider business mailing address

1505 REHOBOTH DR
SEARCY AR
72143-8069
US

V. Phone/Fax

Practice location:
  • Phone: 501-268-2513
  • Fax:
Mailing address:
  • Phone: 214-603-9489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5322
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: