Healthcare Provider Details

I. General information

NPI: 1033226923
Provider Name (Legal Business Name): MARK A DOUGLAS CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT ROOTS DR
NORTH LITTLE ROCK AR
72114-1709
US

IV. Provider business mailing address

1500 S TAYLOR ST
LITTLE ROCK AR
72204-2663
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-3285
  • Fax:
Mailing address:
  • Phone: 501-257-3285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number26219
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: