Healthcare Provider Details

I. General information

NPI: 1669802823
Provider Name (Legal Business Name): PAUL BAILEY III LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1487 W KEISER AVE # 1
OSCEOLA AR
72370-2806
US

IV. Provider business mailing address

404 E BRINKLEY LOOP APT 6
MARION AR
72364-1644
US

V. Phone/Fax

Practice location:
  • Phone: 870-563-4500
  • Fax:
Mailing address:
  • Phone: 870-623-9162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA1311140
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: