=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053300871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAN VANCIL PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2005
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 S MOUNT OLIVE ST
-----------------------------------------------------
City | SILOAM SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72761-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-524-6306
-----------------------------------------------------
Fax | 479-524-6096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51 CHAMPIONS BLVD
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-9568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT205
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | R0639
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------