Healthcare Provider Details

I. General information

NPI: 1053765180
Provider Name (Legal Business Name): MITCHELL REYNOLDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CLUB LN
CONWAY AR
72034-3681
US

IV. Provider business mailing address

550 CLUB LN
CONWAY AR
72034-3681
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-2495
  • Fax: 205-683-2468
Mailing address:
  • Phone: 501-327-2495
  • Fax: 205-683-2468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR2742
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: