=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497711592
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN PRUITT FORD PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2006
-----------------------------------------------------
Last Update Date | 08/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 N JAMES ST STE A
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72076-3167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-241-0410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 N JAMES ST STE A
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72076-3167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-241-0410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA 2046
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------