Healthcare Provider Details

I. General information

NPI: 1972173391
Provider Name (Legal Business Name): MR. ZACHARY CODY DAVID MORAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 N PIERCE ST
LITTLE ROCK AR
72207-5203
US

IV. Provider business mailing address

200 MILLWOOD CIR APT 618
MAUMELLE AR
72113-6344
US

V. Phone/Fax

Practice location:
  • Phone: 501-313-5973
  • Fax:
Mailing address:
  • Phone: 870-351-8106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: