Healthcare Provider Details

I. General information

NPI: 1053613471
Provider Name (Legal Business Name): RODNEY WALLER RECOVERY ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 LOWER RIDGE RD
CONWAY AR
72032-8518
US

IV. Provider business mailing address

PO BOX 1589
BENTON AR
72018-1589
US

V. Phone/Fax

Practice location:
  • Phone: 501-548-9905
  • Fax:
Mailing address:
  • Phone: 501-315-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: