Provider Demographics
NPI:1053840447
Name:BACCHUS, CLINT ALLEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:ALLEN
Last Name:BACCHUS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SKYLINE DR STE A
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-3310
Mailing Address - Country:US
Mailing Address - Phone:479-967-5155
Mailing Address - Fax:479-967-5141
Practice Address - Street 1:115 SKYLINE DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-3310
Practice Address - Country:US
Practice Address - Phone:479-967-5155
Practice Address - Fax:479-967-5141
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4282225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist