Healthcare Provider Details

I. General information

NPI: 1699804484
Provider Name (Legal Business Name): STANLEY ALLAN ESCALANTE LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 PINE ST
ARKADELPHIA AR
71923-4731
US

IV. Provider business mailing address

218 N 11TH ST APT 44
ARKADELPHIA AR
71923-4918
US

V. Phone/Fax

Practice location:
  • Phone: 870-230-8364
  • Fax: 870-230-8381
Mailing address:
  • Phone: 870-403-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA0312103
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: