Provider Demographics
NPI:1750085189
Name:ADVANCED SPINE & THERAPY, LLC
Entity type:Organization
Organization Name:ADVANCED SPINE & THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-216-2315
Mailing Address - Street 1:300 CRESTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-5515
Mailing Address - Country:US
Mailing Address - Phone:479-216-2315
Mailing Address - Fax:479-413-8090
Practice Address - Street 1:300 CRESTWOOD CIR
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-5515
Practice Address - Country:US
Practice Address - Phone:479-216-2315
Practice Address - Fax:479-413-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-29
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR319883742Medicaid