=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427349257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALVERN PHYSICAL THERAPY AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2011
-----------------------------------------------------
Last Update Date | 04/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 HWY 270 W SUITE 104
-----------------------------------------------------
City | MALVERN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-467-8275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1890
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72018-1890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-778-4960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSISTANT
-----------------------------------------------------
Name | PEPPER AUSTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-778-4960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT842
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 3097
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1316
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------