Healthcare Provider Details

I. General information

NPI: 1518564616
Provider Name (Legal Business Name): LUKE RALLENS QBHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 N BUSINESS DR
FAYETTEVILLE AR
72703-5204
US

IV. Provider business mailing address

2885 W BATTLEFIELD ST
SPRINGFIELD MO
65807-3952
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-1532
  • Fax: 479-521-9940
Mailing address:
  • Phone: 417-761-5214
  • Fax: 417-761-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number000
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: