Provider Demographics
NPI:1114116878
Name:CAROLYN MOODY PHYSICAL THERAPY CO.
Entity Type:Organization
Organization Name:CAROLYN MOODY PHYSICAL THERAPY CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-932-5551
Mailing Address - Street 1:217 E CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3372
Mailing Address - Country:US
Mailing Address - Phone:870-932-5551
Mailing Address - Fax:
Practice Address - Street 1:217 E CHERRY AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3372
Practice Address - Country:US
Practice Address - Phone:870-932-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8192251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165343742Medicaid