Healthcare Provider Details

I. General information

NPI: 1225317621
Provider Name (Legal Business Name): MED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 MERRILL DR
LITTLE ROCK AR
72211-1818
US

IV. Provider business mailing address

1604 MERRILL DR
LITTLE ROCK AR
72211-1818
US

V. Phone/Fax

Practice location:
  • Phone: 501-240-5748
  • Fax:
Mailing address:
  • Phone: 501-240-5748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateAR

VIII. Authorized Official

Name: MR. ERIC G WARE
Title or Position: OWNER
Credential:
Phone: 501-240-5748