Healthcare Provider Details

I. General information

NPI: 1942697123
Provider Name (Legal Business Name): SHUNTIA BUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 W 37TH ST
NORTH LITTLE ROCK AR
72118-4832
US

IV. Provider business mailing address

213 LINDENHURST DR
NORTH LITTLE ROCK AR
72118-3104
US

V. Phone/Fax

Practice location:
  • Phone: 501-812-4832
  • Fax:
Mailing address:
  • Phone: 501-626-8507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: