Healthcare Provider Details

I. General information

NPI: 1396021481
Provider Name (Legal Business Name): ROBERT DAVID DYKES LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 KAVANAUGH BLVD SUITE A
LITTLE ROCK AR
72205-3767
US

IV. Provider business mailing address

3000 KAVANAUGH BLVD SUITE A
LITTLE ROCK AR
72205-3767
US

V. Phone/Fax

Practice location:
  • Phone: 501-499-4559
  • Fax:
Mailing address:
  • Phone: 501-499-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7173
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: