Provider Demographics
NPI:1841916707
Name:HOMETOWN PEDIATRIC THERAPY SERVICES
Entity type:Organization
Organization Name:HOMETOWN PEDIATRIC THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:LAW
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:479-965-6062
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:AR
Mailing Address - Zip Code:72933-0332
Mailing Address - Country:US
Mailing Address - Phone:479-965-6062
Mailing Address - Fax:
Practice Address - Street 1:1811 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:AR
Practice Address - Zip Code:72933-9254
Practice Address - Country:US
Practice Address - Phone:479-965-6062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty