Provider Demographics
NPI:1013972629
Name:MENA SPINE & REHAB, PA
Entity type:Organization
Organization Name:MENA SPINE & REHAB, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:479-437-4444
Mailing Address - Street 1:PO BOX 833
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-0833
Mailing Address - Country:US
Mailing Address - Phone:479-437-4444
Mailing Address - Fax:479-437-3361
Practice Address - Street 1:701 MORROW ST S
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-4697
Practice Address - Country:US
Practice Address - Phone:479-437-4444
Practice Address - Fax:479-437-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1573111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159192718Medicaid
1023092863Medicare PIN
AR159192718Medicaid