Provider Demographics
NPI:1790386035
Name:SMITH, JOHN COLIN (PTA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:COLIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PTA
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:870-404-9368
Mailing Address - Fax:870-277-0896
Practice Address - Street 1:416 N MAIN ST STE I
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:AR
Practice Address - Zip Code:72521-9008
Practice Address - Country:US
Practice Address - Phone:870-701-5089
Practice Address - Fax:870-277-0896
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4363225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant