Provider Demographics
NPI:1124017058
Name:KELLY, ROWDY (PT, COMT)
Entity Type:Individual
Prefix:MR
First Name:ROWDY
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT, COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 COUNTY ROAD 643
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-7555
Mailing Address - Country:US
Mailing Address - Phone:870-425-0725
Mailing Address - Fax:
Practice Address - Street 1:200 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3654
Practice Address - Country:US
Practice Address - Phone:870-424-4550
Practice Address - Fax:870-424-4558
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT19782251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y381Medicare ID - Type Unspecified