Provider Demographics
NPI:1609235126
Name:KIDSOURCE THERAPY GROUP, LLC
Entity Type:Organization
Organization Name:KIDSOURCE THERAPY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:JESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-315-4414
Mailing Address - Street 1:17706 I 30 STE 3
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-2930
Mailing Address - Country:US
Mailing Address - Phone:501-315-4414
Mailing Address - Fax:
Practice Address - Street 1:610 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-3922
Practice Address - Country:US
Practice Address - Phone:501-580-3124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation