Healthcare Provider Details

I. General information

NPI: 1528487584
Provider Name (Legal Business Name): DEVARON LAMAR ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 MARY KAY BLVD
BENTON AR
72015-7201
US

IV. Provider business mailing address

PO BOX 1589
BENTON AR
72018-1589
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-3344
  • Fax: 510-381-6118
Mailing address:
  • Phone: 501-315-3344
  • Fax: 510-381-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: