=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316266638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRYANT BETHEL PHYSICAL THERAPY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2010
-----------------------------------------------------
Last Update Date | 12/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 608 W COMMERCE DR SUITE 2
-----------------------------------------------------
City | BRYANT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72022-6202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-847-0107
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 608 W COMMERCE DR SUITE 2
-----------------------------------------------------
City | BRYANT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72022-6202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-847-0107
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. JULIE E GAISER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 501-847-0107
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT1009
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------