Healthcare Provider Details

I. General information

NPI: 1134654213
Provider Name (Legal Business Name): LAURA SHORES RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 HIGHWAY 63 N
HAZEN AR
72064
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 870-255-3696
  • Fax: 870-255-4061
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-347-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1331
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: