Provider Demographics
NPI:1851807424
Name:TIARKS THERAPY SERVICES
Entity Type:Organization
Organization Name:TIARKS THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRISTAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:TIARKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:479-619-5514
Mailing Address - Street 1:1551 N LEXINGTON DR
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-9539
Mailing Address - Country:US
Mailing Address - Phone:479-619-5514
Mailing Address - Fax:
Practice Address - Street 1:2104 S WALTON BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6732
Practice Address - Country:US
Practice Address - Phone:479-619-5514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3288208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR183881721Medicaid