Healthcare Provider Details

I. General information

NPI: 1851419022
Provider Name (Legal Business Name): ROCKY LEE SHANKLE LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 ROGERS AVE STE2
FORT SMITH AR
72903-3046
US

IV. Provider business mailing address

4801 UNION TOWN HWY
VAN BUREN AR
72956
US

V. Phone/Fax

Practice location:
  • Phone: 479-783-0369
  • Fax:
Mailing address:
  • Phone: 479-471-1582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3469
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: