Healthcare Provider Details

I. General information

NPI: 1063311348
Provider Name (Legal Business Name): CHARLES MANCE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2026
Last Update Date: 11/03/2026
Certification Date: 11/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N REYNOLDS RD
BRYANT AR
72022-3024
US

IV. Provider business mailing address

7820 W CAPITOL AVE APT 303
LITTLE ROCK AR
72205-4797
US

V. Phone/Fax

Practice location:
  • Phone: 501-353-3541
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: