Provider Demographics
NPI:1962708867
Name:DAIGLE, MATTHEW (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DAIGLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 I 55 SERVICE RD
Mailing Address - Street 2:STE C
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364
Mailing Address - Country:US
Mailing Address - Phone:870-739-8686
Mailing Address - Fax:870-739-8656
Practice Address - Street 1:2860 I 55 SERVICE RD
Practice Address - Street 2:STE C
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364
Practice Address - Country:US
Practice Address - Phone:870-739-8686
Practice Address - Fax:870-739-8656
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-10
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187353721Medicaid
AR5F804Medicare PIN