Provider Demographics
NPI:1285678052
Name:GRAND PRAIRIE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:GRAND PRAIRIE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JERRIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:870-946-8400
Mailing Address - Street 1:317 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-3279
Mailing Address - Country:US
Mailing Address - Phone:870-946-8400
Mailing Address - Fax:870-946-8511
Practice Address - Street 1:317 W 7TH ST
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:AR
Practice Address - Zip Code:72042-3279
Practice Address - Country:US
Practice Address - Phone:870-946-8400
Practice Address - Fax:870-946-8511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1005261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139762742Medicaid
AR5C554Medicare PIN