Healthcare Provider Details

I. General information

NPI: 1831313006
Provider Name (Legal Business Name): AMBER GLASCOCK OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 MAIN ST
LAKE VILLAGE AR
71653-1916
US

IV. Provider business mailing address

216 MAIN ST
LAKE VILLAGE AR
71653-1916
US

V. Phone/Fax

Practice location:
  • Phone: 870-265-3950
  • Fax: 870-265-2525
Mailing address:
  • Phone: 870-265-3950
  • Fax: 870-265-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOTR2103
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: