Healthcare Provider Details

I. General information

NPI: 1255839767
Provider Name (Legal Business Name): GAREN KENNETH THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 DAVID ST
CORNING AR
72422-7268
US

IV. Provider business mailing address

2707 BROWNS LN
JONESBORO AR
72401-7213
US

V. Phone/Fax

Practice location:
  • Phone: 870-857-3655
  • Fax: 870-857-3667
Mailing address:
  • Phone: 870-972-4961
  • Fax: 870-972-4088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL059578
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: