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NPI Code Detail

MEDICARE: MRS. MIGNON CHIDESTER M.S., P.T.

MEDICARE: MRS. MIGNON CHIDESTER M.S., 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
1225100000XPhysical Therapist1916AR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
15W915OTHERARBCBS

General Provider Information

NPI Number : 1548220510
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MIGNON CHIDESTER M.S., P.T.
Provider Business Mailing Address
First Line : 9500 DARLINGTON WAY
Second Line :
City : FORT SMITH
State : AR
Zip : 72908-9296
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3304 S M ST
Second Line :
City : FORT SMITH
State : AR
Zip : 72903-2903
Country : US
Telephone Number : 479-785-4677
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/24/2006
Last Update Date : 07/08/2007

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