Provider Demographics
NPI:1275698177
Name:PORCH, LAURA (PHYSICAL THERAPISTY)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PORCH
Suffix:
Gender:F
Credentials:PHYSICAL THERAPISTY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NE DYSART WOODS LN
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-8591
Mailing Address - Country:US
Mailing Address - Phone:479-531-8329
Mailing Address - Fax:147-971-5687
Practice Address - Street 1:212 S 3RD ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4547
Practice Address - Country:US
Practice Address - Phone:147-963-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161694721Medicaid
AR5A044OtherBLUE CROSS BLUE SHIELD