Provider Demographics
NPI:1245431964
Name:KINGS RIVER PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:KINGS RIVER PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:870-423-3316
Mailing Address - Street 1:402 W COLLEGE AVE.
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-3142
Mailing Address - Country:US
Mailing Address - Phone:870-423-3316
Mailing Address - Fax:870-423-3177
Practice Address - Street 1:402 W COLLEGE AVE.
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-3142
Practice Address - Country:US
Practice Address - Phone:870-423-3316
Practice Address - Fax:870-423-3177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2047261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154777742Medicaid
AR5Y014OtherBCBS GROUP
AR154777742Medicaid