Provider Demographics
NPI:1023054145
Name:NORTHSIDE THERAPY CENTER INC
Entity type:Organization
Organization Name:NORTHSIDE THERAPY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:JENKINS
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:501-687-0328
Mailing Address - Street 1:4216 E MCCAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117
Mailing Address - Country:US
Mailing Address - Phone:501-687-0328
Mailing Address - Fax:501-687-0330
Practice Address - Street 1:4216 E MCCAIN BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117
Practice Address - Country:US
Practice Address - Phone:501-687-0328
Practice Address - Fax:501-687-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0000001458261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR682617OtherACN PROVIDER NUMBER
AR4439380001OtherPALMETTO GBA DME
ARCJ8952OtherPALMETTO RAILROAD MCARE
AR7891261OtherAETNA
AR5C512OtherBLUE CROSS BLUE SHIELD
AR4439380001OtherPALMETTO GBA DME
AR682617OtherACN PROVIDER NUMBER
AR7891261OtherAETNA
AR5C512OtherBLUE CROSS BLUE SHIELD
AR5C512Medicare PIN