Provider Demographics
NPI:1720607443
Name:ROGUE THERAPY PROFESSIONALS PLLC
Entity Type:Organization
Organization Name:ROGUE THERAPY PROFESSIONALS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-453-3361
Mailing Address - Street 1:14030 HUMMINGBIRD RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-0358
Mailing Address - Country:US
Mailing Address - Phone:501-733-6113
Mailing Address - Fax:
Practice Address - Street 1:14030 HUMMINGBIRD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-0358
Practice Address - Country:US
Practice Address - Phone:501-733-6113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-13
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty