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General NPI Number Information
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NPI Number | 1558773671
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE BALANCE PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 05/22/2014
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Last Update Date | 05/22/2014
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Provider Practice Location Address
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Address Line | 1706 NW MYSTIC AVE
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City | BENTONVILLE
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State | AR
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Zip | 72712-8094
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Country | US
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Telephone | 479-372-8783
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Fax |
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Provider Business Mailing Address
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Address Line | 1706 NW MYSTIC AVE
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City | BENTONVILLE
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State | AR
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Zip | 72712-8094
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Country | US
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Telephone | 479-372-8783
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JENNIFER LYNN VINCENZO
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Credential | PT, MPH, CHES, GCS
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Telephone | 479-372-8783
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 3069
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License Number State | AR
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