MEDICARE: DALE HENRY MENNA MSPT

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	2961	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	289473YQCR	OTHER	AR	MEDICARE PTAN

General Provider Information

NPI Number	:	1174663009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALE HENRY MENNA MSPT

Provider Business Mailing Address
First Line	:	800 FAIR PARK BLVD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72204-1720
Country	:	US
Telephone Number	:	501-500-3500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3480 LANDERS RD
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72117-2541
Country	:	US
Telephone Number	:	501-500-3500
Fax Number	:

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

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	08/05/2019

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