Provider Demographics
NPI:1275503278
Name:GROVE STREET PHYSICAL THERPAY CLINIC & REHAB SVCS INC
Entity Type:Organization
Organization Name:GROVE STREET PHYSICAL THERPAY CLINIC & REHAB SVCS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-862-4042
Mailing Address - Street 1:203 W GROVE ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4646
Mailing Address - Country:US
Mailing Address - Phone:870-862-4042
Mailing Address - Fax:870-864-0218
Practice Address - Street 1:203 W GROVE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4646
Practice Address - Country:US
Practice Address - Phone:870-862-4042
Practice Address - Fax:870-864-0218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C239OtherARK BLUE CROSS B/S
AR5C239OtherARK BLUE CROSS B/S