=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083431514
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER ALAN TOLBERT PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2024
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 NORTHRIDGE DR STE E
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-6544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-452-4892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 NORTHRIDGE DR STE E
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-6544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-452-4892
-----------------------------------------------------
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 | PT2236
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------