Healthcare Provider Details

I. General information

NPI: 1518232289
Provider Name (Legal Business Name): TYLEIGH DODGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 NASHVILLE RD
HORSESHOE BEND AR
72512-3110
US

IV. Provider business mailing address

1304 NASHVILLE RD
HORSESHOE BEND AR
72512-3110
US

V. Phone/Fax

Practice location:
  • Phone: 870-750-0694
  • Fax:
Mailing address:
  • Phone: 870-750-0694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: