Healthcare Provider Details

I. General information

NPI: 1154360576
Provider Name (Legal Business Name): LITTLE ROCK ALLERGY & ASTHMA CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 CORPORATE HILL DR SUITE 110
LITTLE ROCK AR
72205-4565
US

IV. Provider business mailing address

18 CORPORATE HILL DRIVE SUITE 110
LITTLE ROCK AR
72205-4565
US

V. Phone/Fax

Practice location:
  • Phone: 501-224-1156
  • Fax: 501-801-5561
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMC0750
License Number StateAR

VIII. Authorized Official

Name: JENNIFER WAKE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 501-978-7113