Healthcare Provider Details

I. General information

NPI: 1598969412
Provider Name (Legal Business Name): CAMILA ROSE ANTIQUIERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S AVALON ST
WEST MEMPHIS AR
72301-4109
US

IV. Provider business mailing address

1350 S AVALON ST APT 4
WEST MEMPHIS AR
72301-6277
US

V. Phone/Fax

Practice location:
  • Phone: 870-400-3481
  • Fax:
Mailing address:
  • Phone: 870-702-6940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT2791
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: