Healthcare Provider Details

I. General information

NPI: 1154322261
Provider Name (Legal Business Name): BARBARA GRAVES INTIMATE FASHIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10301 N RODNEY PARHAM RD
LITTLE ROCK AR
72227-4832
US

IV. Provider business mailing address

10301 N RODNEY PARHAM RD
LITTLE ROCK AR
72227-4832
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-5537
  • Fax: 501-227-0655
Mailing address:
  • Phone: 501-227-5537
  • Fax: 501-227-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number02063560001
License Number StateAR

VIII. Authorized Official

Name: TRINA BRICKEY
Title or Position: STORE MANAGER
Credential:
Phone: 501-227-5537