Healthcare Provider Details

I. General information

NPI: 1841585643
Provider Name (Legal Business Name): CODY RAGLAND MHPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 SE WALTON BLVD
BENTONVILLE AR
72712-3725
US

IV. Provider business mailing address

3352 N FUTRALL DR
FAYETTEVILLE AR
72703-4057
US

V. Phone/Fax

Practice location:
  • Phone: 479-464-5925
  • Fax: 479-464-4275
Mailing address:
  • Phone: 479-521-1427
  • Fax: 479-521-6520

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: