Provider Demographics
NPI:1962642900
Name:MARTIN BOWEN HEFLEY KNEE & SPORTS MED. CTR.
Entity Type:Organization
Organization Name:MARTIN BOWEN HEFLEY KNEE & SPORTS MED. CTR.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-663-6455
Mailing Address - Street 1:5 SAINT VINCENT CIR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5412
Mailing Address - Country:US
Mailing Address - Phone:501-663-4320
Mailing Address - Fax:501-978-1452
Practice Address - Street 1:5 SAINT VINCENT CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5412
Practice Address - Country:US
Practice Address - Phone:501-663-4320
Practice Address - Fax:501-978-1452
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTIN BOWEN HEFLEY KNEE & SPORTS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-04
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152501742Medicaid