Provider Demographics
NPI:1104855261
Name:LANE PHYSICAL THERAPY CENTER, INC
Entity Type:Organization
Organization Name:LANE PHYSICAL THERAPY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-967-9657
Mailing Address - Street 1:3016 W. MAIN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2453
Mailing Address - Country:US
Mailing Address - Phone:479-967-9657
Mailing Address - Fax:479-967-9658
Practice Address - Street 1:3016 W. MAIN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2453
Practice Address - Country:US
Practice Address - Phone:479-967-9657
Practice Address - Fax:479-967-9658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1836208100000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136075742Medicaid
AR136075742Medicaid