Healthcare Provider Details

I. General information

NPI: 1396783338
Provider Name (Legal Business Name): PAIN MANAGEMENT & REHAB CONSULT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2531 TINAS CROSSING
FAYETTEVILLE AR
72703
US

IV. Provider business mailing address

PO BOX 9928
FAYETTEVILLE AR
72701
US

V. Phone/Fax

Practice location:
  • Phone: 479-587-8753
  • Fax: 479-587-8754
Mailing address:
  • Phone: 479-587-8753
  • Fax: 479-587-8754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberE4333
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberMC2421
License Number StateAR

VIII. Authorized Official

Name: MRS. FELISHA F HARP
Title or Position: OFFICE MANAGER BILLING
Credential:
Phone: 479-587-1753