Healthcare Provider Details

I. General information

NPI: 1104955814
Provider Name (Legal Business Name): DAVID A. RUBLE LPE-I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 AMITY RD STE 604
CONWAY AR
72032-5993
US

IV. Provider business mailing address

505 AMITY RD STE 604
CONWAY AR
72032-5993
US

V. Phone/Fax

Practice location:
  • Phone: 501-825-3100
  • Fax: 501-367-7677
Mailing address:
  • Phone: 501-825-3100
  • Fax: 501-367-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number95-11EI
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: