Healthcare Provider Details

I. General information

NPI: 1518539659
Provider Name (Legal Business Name): PRESTIGE SPINE WEST LITTLE ROCK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 RAHLING RD
LITTLE ROCK AR
72223-4677
US

IV. Provider business mailing address

1811 RAHLING RD
LITTLE ROCK AR
72223-4677
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-2220
  • Fax:
Mailing address:
  • Phone: 501-227-2220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: APRIL JOHNSON
Title or Position: MANAGER
Credential:
Phone: 601-540-5450