=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902335581
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED THERAPY CONNECTION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2017
-----------------------------------------------------
Last Update Date | 06/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 HIGHWAY 62 412 STE L
-----------------------------------------------------
City | ASH FLAT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72513-9629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-262-7480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 723
-----------------------------------------------------
City | CHEROKEE VILLAGE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72525-0723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORGANIZER
-----------------------------------------------------
Name | DARRYL MATSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-847-2448
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------