Provider Demographics
NPI:1649397076
Name:GROSS, LANCE (PT)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2398
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-2398
Mailing Address - Country:US
Mailing Address - Phone:870-404-5299
Mailing Address - Fax:
Practice Address - Street 1:347 HIGHWAY 62 E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3655
Practice Address - Country:US
Practice Address - Phone:870-701-5089
Practice Address - Fax:870-277-0896
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131825721Medicaid