Provider Demographics
NPI:1134341381
Name:BRUCE WOLF PHYSICAL THERAPY, P.A.
Entity type:Organization
Organization Name:BRUCE WOLF PHYSICAL THERAPY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:CAR
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:870-425-5180
Mailing Address - Street 1:607 NORTHTOWN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3121
Mailing Address - Country:US
Mailing Address - Phone:870-425-5180
Mailing Address - Fax:870-425-5185
Practice Address - Street 1:607 NORTHTOWN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3121
Practice Address - Country:US
Practice Address - Phone:870-425-5180
Practice Address - Fax:870-425-5185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARS72859Medicare UPIN
AR5U255Medicare ID - Type Unspecified