Healthcare Provider Details

I. General information

NPI: 1407001720
Provider Name (Legal Business Name): SAMUEL CARY KELSO AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 ADA AVE SUITE 202
CONWAY AR
72034-4985
US

IV. Provider business mailing address

2200 ADA AVE SUITE 202
CONWAY AR
72034-4985
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-3929
  • Fax: 501-329-3816
Mailing address:
  • Phone: 501-327-3929
  • Fax: 501-329-3816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberA147
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: