Healthcare Provider Details

I. General information

NPI: 1740295609
Provider Name (Legal Business Name): PHILIP EDWARD BLAND D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903A N BLOOMINGTON ST STE 103
LOWELL AR
72745-9612
US

IV. Provider business mailing address

903A N BLOOMINGTON ST STE 103
LOWELL AR
72745-9612
US

V. Phone/Fax

Practice location:
  • Phone: 479-633-8917
  • Fax:
Mailing address:
  • Phone: 479-633-8917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1594
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: