Basic Information
| Provider Information | |||||||||
| NPI: | 1861594673 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSIQUES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SOUTH ARKANSAS CARDIAC REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 N DUDNEY RD STE E | ||||||||
| Address2: | |||||||||
| City: | MAGNOLIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717532651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702343488 | ||||||||
| FaxNumber: | 8702343488 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 N DUDNEY RD STE D | ||||||||
| Address2: | |||||||||
| City: | MAGNOLIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717532651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702343488 | ||||||||
| FaxNumber: | 8702343488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FALLIN | ||||||||
| AuthorizedOfficialFirstName: | LEANNE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8702343488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BSE, RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 148073002 | 05 | AR | MEDICAID |