Provider Demographics
NPI:1912572025
Name:DO PT LLC
Entity Type:Organization
Organization Name:DO PT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, FIT
Authorized Official - Phone:318-792-7987
Mailing Address - Street 1:1214 SALEM ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019
Mailing Address - Country:US
Mailing Address - Phone:318-792-7987
Mailing Address - Fax:501-457-9090
Practice Address - Street 1:1214 SALEM ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019
Practice Address - Country:US
Practice Address - Phone:318-792-7987
Practice Address - Fax:501-457-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty