MEDICARE: PRIMARILY PEDIATRICS, INC

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	1593	AR

General Provider Information

NPI Number	:	1942266440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARILY PEDIATRICS, INC

Provider Business Mailing Address
First Line	:	PO BOX 322
Second Line	:
City	:	MORRILTON
State	:	AR
Zip	:	72110-0322
Country	:	US
Telephone Number	:	501-354-1133
Fax Number	:	501-354-1133

Provider Business Practice Location Address
First Line	:	4912 HIGHWAY 9
Second Line	:
City	:	SPRINGFIELD
State	:	AR
Zip	:	72157-9669
Country	:	US
Telephone Number	:	501-354-1133
Fax Number	:	501-354-1133

Authorized Official
Title or Position	:	PRES
Name	:	MRS. DJUANA FRESNEDA BECK
Credential	:	MS, PT
Telephone Number	:	501-354-1133

Provider Enumeration Date	:	04/24/2006
Last Update Date	:	08/22/2020

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