Healthcare Provider Details

I. General information

NPI: 1730124132
Provider Name (Legal Business Name): LAWRENCE EDWARD MCKLVEEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 08/21/2007
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 2197
BATESVILLE AR
72503-2197
US

V. Phone/Fax

Practice location:
  • Phone: 870-262-1200
  • Fax: 870-262-6063
Mailing address:
  • Phone: 870-262-1200
  • Fax: 870-262-6063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC00626
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: