Provider Demographics
NPI:1144249103
Name:BOSTON MOUNTAIN HEALTHCARE SERVICES INC.
Entity type:Organization
Organization Name:BOSTON MOUNTAIN HEALTHCARE SERVICES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:479-667-3710
Mailing Address - Street 1:257 AIRPORT RD
Mailing Address - Street 2:STE. E
Mailing Address - City:OZARK
Mailing Address - State:AR
Mailing Address - Zip Code:72949-9200
Mailing Address - Country:US
Mailing Address - Phone:479-667-3710
Mailing Address - Fax:479-667-3712
Practice Address - Street 1:257 AIRPORT RD
Practice Address - Street 2:STE. E
Practice Address - City:OZARK
Practice Address - State:AR
Practice Address - Zip Code:72949-9200
Practice Address - Country:US
Practice Address - Phone:479-667-3710
Practice Address - Fax:479-667-3712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2698225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F466Medicare ID - Type Unspecified