Healthcare Provider Details

I. General information

NPI: 1801636485
Provider Name (Legal Business Name): REID BLAYLOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 SPRINGHILL DR
NORTH LITTLE ROCK AR
72117-2922
US

IV. Provider business mailing address

224 COPPER WAY
LITTLE ROCK AR
72223-4038
US

V. Phone/Fax

Practice location:
  • Phone: 501-202-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number148818
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: