Provider Demographics
NPI:1346336245
Name:TRI-LAKES PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:TRI-LAKES PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:T
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:501-623-6353
Mailing Address - Street 1:307 CARPENTER DAM RD
Mailing Address - Street 2:BLDG. L
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-8218
Mailing Address - Country:US
Mailing Address - Phone:501-623-6353
Mailing Address - Fax:501-321-4783
Practice Address - Street 1:307 CARPENTER DAM ROAD
Practice Address - Street 2:BLDG. L
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-8218
Practice Address - Country:US
Practice Address - Phone:501-623-6353
Practice Address - Fax:501-321-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 1481261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C316Medicare UPIN
ARQ10814Medicare UPIN