Healthcare Provider Details

I. General information

NPI: 1912662206
Provider Name (Legal Business Name): DOMINIQUE MAURICE GRAY-COATS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 BROADWAY ST
LITTLE ROCK AR
72206-2149
US

IV. Provider business mailing address

6005 VALERIE DR
NORTH LITTLE ROCK AR
72118-3180
US

V. Phone/Fax

Practice location:
  • Phone: 501-612-4068
  • Fax:
Mailing address:
  • Phone: 501-612-4068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: