=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861007841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDEN SHANE BLUME PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2020
-----------------------------------------------------
Last Update Date | 09/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 S SOUTHERN HILLS CT # 200
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-636-1324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6104 EVERGREEN DR
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72207-6312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-871-5330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | PT4849
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------