Provider Demographics
NPI:1992907067
Name:FENTER PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:FENTER PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:FENTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:870-761-6463
Mailing Address - Street 1:101 GEORGETOWN DR
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-3805
Mailing Address - Country:US
Mailing Address - Phone:870-629-9413
Mailing Address - Fax:
Practice Address - Street 1:2860 I-55 SERVICE ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364
Practice Address - Country:US
Practice Address - Phone:870-629-9413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2837225100000X
ARPT2812225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F804Medicare PIN