Healthcare Provider Details

I. General information

NPI: 1174583280
Provider Name (Legal Business Name): AMANDA RAE BLEDSOE D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 AMITY RD
CONWAY AR
72032-5991
US

IV. Provider business mailing address

775 AMITY RD
CONWAY AR
72032-5991
US

V. Phone/Fax

Practice location:
  • Phone: 501-504-6999
  • Fax: 501-205-8431
Mailing address:
  • Phone: 501-504-6999
  • Fax: 501-205-8431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1663
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: