Healthcare Provider Details

I. General information

NPI: 1023092863
Provider Name (Legal Business Name): KERVIN T PUTMAN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 MENA ST
MENA AR
71953-3337
US

IV. Provider business mailing address

PO BOX 833
MENA AR
71953-0833
US

V. Phone/Fax

Practice location:
  • Phone: 479-437-4444
  • Fax: 479-437-3361
Mailing address:
  • Phone: 479-437-4444
  • Fax: 479-437-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1573
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: