Healthcare Provider Details

I. General information

NPI: 1104377761
Provider Name (Legal Business Name): ORESTES ORTEGA III HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 E JOYCE BLVD STE 2
FAYETTEVILLE AR
72703-5162
US

IV. Provider business mailing address

1970 E JOYCE BLVD STE 2
FAYETTEVILLE AR
72703-5162
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-6511
  • Fax: 479-443-7811
Mailing address:
  • Phone: 479-443-6511
  • Fax: 479-443-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number611
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: