=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891339719
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKFIELD PHYSICAL REHABILITATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2019
-----------------------------------------------------
Last Update Date | 11/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 SAWTOOTH OAK ST
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71901-7169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-520-0016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 W DOUGLAS AVE STE 950
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67202-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-682-6770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTORIZED OFFICIAL
-----------------------------------------------------
Name | JOSEPH J HLAVACEK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 316-682-6770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------