Provider Demographics
NPI:1518384536
Name:FENTER PHYSICAL THERAPY
Entity Type:Organization
Organization Name:FENTER PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FENTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:870-394-7000
Mailing Address - Street 1:605 N RIVERWIND
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364
Mailing Address - Country:US
Mailing Address - Phone:870-394-7000
Mailing Address - Fax:870-394-7001
Practice Address - Street 1:200 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3904
Practice Address - Country:US
Practice Address - Phone:870-394-7000
Practice Address - Fax:870-394-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR198689716Medicaid