Healthcare Provider Details

I. General information

NPI: 1639585805
Provider Name (Legal Business Name): JUSTIN CONWAY RECOVERY ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 MARTIN LN
ASH FLAT AR
72513-9749
US

IV. Provider business mailing address

PO BOX 1589
BENTON AR
72018-1589
US

V. Phone/Fax

Practice location:
  • Phone: 870-994-2848
  • Fax:
Mailing address:
  • Phone: 501-315-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: