Healthcare Provider Details

I. General information

NPI: 1548426034
Provider Name (Legal Business Name): LYNDAL GREEN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11517 KANIS RD
LITTLE ROCK AR
72211-3724
US

IV. Provider business mailing address

5 CHRISTOPHER CV
LITTLE ROCK AR
72223-2166
US

V. Phone/Fax

Practice location:
  • Phone: 501-993-8707
  • Fax: 501-223-8075
Mailing address:
  • Phone: 501-227-0083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberOTR335
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: