Provider Demographics
NPI:1659437945
Name:MILLENNIUM REHAB OF ARKANSAS LLC
Entity Type:Organization
Organization Name:MILLENNIUM REHAB OF ARKANSAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:SY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKSEFAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-931-6789
Mailing Address - Street 1:810 JOE BROOKS DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4133
Mailing Address - Country:US
Mailing Address - Phone:870-931-6789
Mailing Address - Fax:870-931-4363
Practice Address - Street 1:810 JOE BROOKS DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4133
Practice Address - Country:US
Practice Address - Phone:870-931-6789
Practice Address - Fax:870-931-4363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========OtherEIN
AR046582Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER