Provider Demographics
NPI:1265737548
Name:PROFESSIONAL FOR AGILITY CARE LLC
Entity type:Organization
Organization Name:PROFESSIONAL FOR AGILITY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELILA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEJERANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-704-9800
Mailing Address - Street 1:PO BOX 861
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-0861
Mailing Address - Country:US
Mailing Address - Phone:870-704-9800
Mailing Address - Fax:479-770-5656
Practice Address - Street 1:212 S LINCOLN ST
Practice Address - Street 2:STE D
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9782
Practice Address - Country:US
Practice Address - Phone:870-704-9800
Practice Address - Fax:479-770-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty