Healthcare Provider Details

I. General information

NPI: 1639579345
Provider Name (Legal Business Name): EMMITT KNOWLES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HENDERSON ST
ARKADELPHIA AR
71999-0001
US

IV. Provider business mailing address

1100 HENDERSON ST
ARKADELPHIA AR
71999-0001
US

V. Phone/Fax

Practice location:
  • Phone: 870-277-8528
  • Fax:
Mailing address:
  • Phone: 870-277-8528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number928301511
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: