Healthcare Provider Details

I. General information

NPI: 1588950679
Provider Name (Legal Business Name): CHRISTOPHER SPENCER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 HIGHWAY 425 N
MONTICELLO AR
71655-3954
US

IV. Provider business mailing address

5537 BLEAUX AVE
SPRINGDALE AR
72762-0737
US

V. Phone/Fax

Practice location:
  • Phone: 870-367-2141
  • Fax: 870-367-2103
Mailing address:
  • Phone: 479-872-5580
  • Fax: 479-872-5581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: