Healthcare Provider Details

I. General information

NPI: 1144768235
Provider Name (Legal Business Name): LORI G MAIN TECHNICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 W MAIN ST SUITE 3
JACKSONVILLE AR
72076-4207
US

IV. Provider business mailing address

2227 W MAIN ST SUITE 3
JACKSONVILLE AR
72076-4207
US

V. Phone/Fax

Practice location:
  • Phone: 501-985-9944
  • Fax: 501-985-6590
Mailing address:
  • Phone: 501-985-9944
  • Fax: 501-985-6590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: