Provider Demographics
NPI:1992996003
Name:PRISTINE HEALTH LLC
Entity type:Organization
Organization Name:PRISTINE HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:COTHERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-751-8437
Mailing Address - Street 1:7058 W SUNSET AVE
Mailing Address - Street 2:SUITE 9A
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-0680
Mailing Address - Country:US
Mailing Address - Phone:479-751-8437
Mailing Address - Fax:479-802-0575
Practice Address - Street 1:7058 W SUNSET AVE
Practice Address - Street 2:SUITE 9A
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0680
Practice Address - Country:US
Practice Address - Phone:479-751-8437
Practice Address - Fax:479-802-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2286261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163436721Medicaid
AR5A004OtherBLUE CROSS BLUE SHIELD
AR046601OtherMEDICARE PTAN
AR046601OtherMEDICARE PTAN