Provider Demographics
NPI:1992216642
Name:3D PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:3D PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:BACCHUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:479-746-4899
Mailing Address - Street 1:357 COUNTY ROAD 3681
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:AR
Mailing Address - Zip Code:72846-8895
Mailing Address - Country:US
Mailing Address - Phone:479-746-4899
Mailing Address - Fax:
Practice Address - Street 1:510 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3746
Practice Address - Country:US
Practice Address - Phone:479-746-4899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-21
Last Update Date:2017-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4282261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy