Provider Demographics
NPI:1548252653
Name:DAVIS, VAN H (MSPT)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:H
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 KANIS RD
Mailing Address - Street 2:STE D4
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211
Mailing Address - Country:US
Mailing Address - Phone:501-221-6009
Mailing Address - Fax:501-801-1065
Practice Address - Street 1:11900 KANIS RD
Practice Address - Street 2:STE D4
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211
Practice Address - Country:US
Practice Address - Phone:501-221-6009
Practice Address - Fax:501-801-1065
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142776721Medicaid
AR154767742Medicaid
AR154767742Medicaid
AR142776721Medicaid