Healthcare Provider Details

I. General information

NPI: 1427787118
Provider Name (Legal Business Name): MARIECA PRIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7415 COLONEL GLENN RD STE 23
LITTLE ROCK AR
72204-7612
US

IV. Provider business mailing address

4 ELKHART CT
LITTLE ROCK AR
72204-3408
US

V. Phone/Fax

Practice location:
  • Phone: 501-658-4395
  • Fax:
Mailing address:
  • Phone: 501-777-2541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number137644
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: