Healthcare Provider Details

I. General information

NPI: 1295890226
Provider Name (Legal Business Name): LISA M COULTER REEGT,RPSGT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 CONGO SUITE 900
BENTON AR
72015-2750
US

IV. Provider business mailing address

PO BOX 8694
HOT SPRINGS VILLAGE AR
71910-8694
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-8818
  • Fax: 501-315-8828
Mailing address:
  • Phone: 501-860-6130
  • Fax: 501-860-6054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: