MEDICARE: KENNY A DE LUCA P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT2475	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5F332	OTHER	AR	AR BCBS GROUP
2	5W795	OTHER	AR	AR BCBS INDIVIDUAL

General Provider Information

NPI Number	:	1114901451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNY A DE LUCA P.T.

Provider Business Mailing Address
First Line	:	PO BOX 13567
Second Line	:
City	:	MAUMELLE
State	:	AR
Zip	:	72113-0567
Country	:	US
Telephone Number	:	501-753-2201
Fax Number	:	501-753-2207

Provider Business Practice Location Address
First Line	:	9843 MAUMELLE BLVD
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72113-7027
Country	:	US
Telephone Number	:	501-753-2201
Fax Number	:	501-753-2207

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	05/10/2011

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