Provider Demographics
NPI:1790905313
Name:KILCREASE, DAVID (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KILCREASE
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 1:210 W BOLLING ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-5506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 S BRADLEY ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671-3459
Practice Address - Country:US
Practice Address - Phone:870-226-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist