Healthcare Provider Details

I. General information

NPI: 1588477715
Provider Name (Legal Business Name): STEVE GRIDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 CALVIN RD
AMITY AR
71921
US

IV. Provider business mailing address

918 CALVIN RD
AMITY AR
71921
US

V. Phone/Fax

Practice location:
  • Phone: 501-282-5214
  • Fax:
Mailing address:
  • Phone: 501-282-5214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number904407890
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: