Basic Information
Provider Information | |||||||||
NPI: | 1114223724 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOX | ||||||||
FirstName: | ASHLEY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2740 COLLEGE AVE | ||||||||
Address2: |   | ||||||||
City: | CONWAY | ||||||||
State: | AR | ||||||||
PostalCode: | 720346141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013295459 | ||||||||
FaxNumber: | 5013271738 | ||||||||
Practice Location | |||||||||
Address1: | 2860 I-55 SERVICE RD | ||||||||
Address2: | STE C | ||||||||
City: | MARION | ||||||||
State: | AR | ||||||||
PostalCode: | 72364 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703947000 | ||||||||
FaxNumber: | 8703947001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2011 | ||||||||
LastUpdateDate: | 05/23/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   | AR | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 185792721 | 05 | AR |   | MEDICAID |