Provider Demographics
NPI:1730163072
Name:MAUMELLE PHYSICAL THERAPY
Entity type:Organization
Organization Name:MAUMELLE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DE LUCA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:501-753-2201
Mailing Address - Street 1:PO BOX 13567
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-0567
Mailing Address - Country:US
Mailing Address - Phone:501-753-2201
Mailing Address - Fax:501-753-2207
Practice Address - Street 1:9843 MAUMELLE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72113-7027
Practice Address - Country:US
Practice Address - Phone:501-851-6600
Practice Address - Fax:501-851-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157828742Medicaid
AR5F332OtherAR BCBS
AR5W795F332Medicare ID - Type UnspecifiedMEDICARE PART B