Provider Demographics
NPI:1568959179
Name:KIDDOS THERAPY
Entity Type:Organization
Organization Name:KIDDOS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSTURIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:479-970-8351
Mailing Address - Street 1:1706 W 3RD PL
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-4740
Mailing Address - Country:US
Mailing Address - Phone:479-970-8351
Mailing Address - Fax:479-567-5582
Practice Address - Street 1:915 W B ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3501
Practice Address - Country:US
Practice Address - Phone:479-970-8351
Practice Address - Fax:479-567-5582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation