MEDICARE: BLUE ROSE PHYSICAL THERAPY - SALINE

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

General Provider Information

NPI Number	:	1912572025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE ROSE PHYSICAL THERAPY - SALINE

Provider Business Mailing Address
First Line	:	1214 SALEM RD STE A
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72019-8340
Country	:	US
Telephone Number	:	501-915-4354
Fax Number	:	501-457-9090

Provider Business Practice Location Address
First Line	:	1214 SALEM ROAD
Second Line	:	SUITE A
City	:	BENTON
State	:	AR
Zip	:	72019
Country	:	US
Telephone Number	:	318-792-7987
Fax Number	:	501-457-9090

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DOUGLAS LOGAN DISTEFANO
Credential	:	PT, DPT, FAAOMPT
Telephone Number	:	501-915-4354

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	03/17/2026

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