Provider Demographics
NPI:1104432327
Name:USCOCOVICH, SANTIAGO (PTA)
Entity type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:
Last Name:USCOCOVICH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1419
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:AR
Mailing Address - Zip Code:72002-3419
Mailing Address - Country:US
Mailing Address - Phone:501-213-0594
Mailing Address - Fax:
Practice Address - Street 1:2700 N PRICKETT RD STE 2
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-7511
Practice Address - Country:US
Practice Address - Phone:501-213-0594
Practice Address - Fax:844-272-0941
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4576225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant