Healthcare Provider Details

I. General information

NPI: 1326273830
Provider Name (Legal Business Name): BLAINE C DORE' CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 HARRISON ST
BATESVILLE AR
72501-7303
US

IV. Provider business mailing address

PO BOX 4377
BATESVILLE AR
72503-4377
US

V. Phone/Fax

Practice location:
  • Phone: 870-262-3280
  • Fax: 870-262-3284
Mailing address:
  • Phone: 870-262-3280
  • Fax: 870-262-3284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCTP000105
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: