Healthcare Provider Details

I. General information

NPI: 1972123636
Provider Name (Legal Business Name): DUC (DOUGLAS) TRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 E CENTERTON BLVD
CENTERTON AR
72719-9208
US

IV. Provider business mailing address

116 NW APPLE BLOSSOM
BENTONVILLE AR
72712-8424
US

V. Phone/Fax

Practice location:
  • Phone: 479-936-1668
  • Fax:
Mailing address:
  • Phone: 479-936-1668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8424
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: