Provider Demographics
NPI:1992706477
Name:LONOKE PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:LONOKE PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:H
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:501-676-5540
Mailing Address - Street 1:1515 N CENTER ST
Mailing Address - Street 2:#3
Mailing Address - City:LONOKE
Mailing Address - State:AR
Mailing Address - Zip Code:72086-2101
Mailing Address - Country:US
Mailing Address - Phone:501-676-5540
Mailing Address - Fax:501-676-6499
Practice Address - Street 1:1515 N CENTER ST
Practice Address - Street 2:#3
Practice Address - City:LONOKE
Practice Address - State:AR
Practice Address - Zip Code:72086-2101
Practice Address - Country:US
Practice Address - Phone:501-676-5540
Practice Address - Fax:501-676-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1452261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B641Medicare ID - Type Unspecified