Healthcare Provider Details

I. General information

NPI: 1669623492
Provider Name (Legal Business Name): CARROLL EUGENE WALLS JR. OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 RIVERFRONT DRIVE
LITTLE ROCK AR
72202-3121
US

IV. Provider business mailing address

10712 YOSEMITE VALLEY DR
LITTLE ROCK AR
72212-3659
US

V. Phone/Fax

Practice location:
  • Phone: 501-663-6965
  • Fax: 501-603-0675
Mailing address:
  • Phone: 501-681-4448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR592
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: