Provider Demographics
NPI:1497770242
Name:GRAND PRAIRIE PHYSICAL THERAPY OF STUTTGART, INC.
Entity Type:Organization
Organization Name:GRAND PRAIRIE PHYSICAL THERAPY OF STUTTGART, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-673-7679
Mailing Address - Street 1:2105 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STUTTGART
Mailing Address - State:AR
Mailing Address - Zip Code:72160
Mailing Address - Country:US
Mailing Address - Phone:870-673-7679
Mailing Address - Fax:870-673-7654
Practice Address - Street 1:2105 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STUTTGART
Practice Address - State:AR
Practice Address - Zip Code:72160
Practice Address - Country:US
Practice Address - Phone:870-673-7679
Practice Address - Fax:870-673-7654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
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
AR150837742Medicaid
AR=========30OtherQUALCHOICE