Healthcare Provider Details

I. General information

NPI: 1922095710
Provider Name (Legal Business Name): REBA FLOIS THOMPSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703-1944
US

IV. Provider business mailing address

21815 CINDY RD
SPRINGDALE AR
72764-9058
US

V. Phone/Fax

Practice location:
  • Phone: 479-444-5043
  • Fax: 479-587-5949
Mailing address:
  • Phone: 479-466-6272
  • Fax: 479-587-5949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1324
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number528
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: