Healthcare Provider Details

I. General information

NPI: 1952959934
Provider Name (Legal Business Name): MR. KYLE JEWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 MENA ST
MENA AR
71953-3339
US

IV. Provider business mailing address

605 MENA ST
MENA AR
71953-3339
US

V. Phone/Fax

Practice location:
  • Phone: 479-385-1236
  • Fax: 479-437-3786
Mailing address:
  • Phone: 479-385-1236
  • Fax: 479-437-3786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: