Provider Demographics
NPI:1184982894
Name:PHYSICAL THERAPY ADVANTAGE, LLC
Entity type:Organization
Organization Name:PHYSICAL THERAPY ADVANTAGE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:501-519-0144
Mailing Address - Street 1:52 DUCLAIR CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-9570
Mailing Address - Country:US
Mailing Address - Phone:501-519-0144
Mailing Address - Fax:
Practice Address - Street 1:52 DUCLAIR CT
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-9570
Practice Address - Country:US
Practice Address - Phone:501-519-0144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1240302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1225144793OtherKELLEY GLENN