Provider Demographics
NPI:1134258981
Name:PREMIERE PHYSICAL THERAPY AND SPORTS REHAB LLC
Entity type:Organization
Organization Name:PREMIERE PHYSICAL THERAPY AND SPORTS REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-273-9933
Mailing Address - Street 1:203 SE 22ND ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4310
Mailing Address - Country:US
Mailing Address - Phone:479-273-9933
Mailing Address - Fax:479-273-9935
Practice Address - Street 1:203 SE 22ND ST
Practice Address - Street 2:SUITE 9
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4310
Practice Address - Country:US
Practice Address - Phone:479-273-9933
Practice Address - Fax:479-273-9935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR796247OtherHEALTHLINK
AR712695OtherACN GROUP
AR19435OtherEVOLUTIONS
AR5A315OtherBCBS
AR164492742Medicaid
AR=========00OtherQUALCHOICE
AR19435OtherEVOLUTIONS
AR5F768Medicare PIN