Provider Demographics
NPI:1386004653
Name:SIBLEY, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SIBLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CHALICE DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-7825
Mailing Address - Country:US
Mailing Address - Phone:205-259-3991
Mailing Address - Fax:205-683-2468
Practice Address - Street 1:550 CLUB LN
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3681
Practice Address - Country:US
Practice Address - Phone:205-259-3991
Practice Address - Fax:205-683-2468
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3592225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist