Healthcare Provider Details

I. General information

NPI: 1447245626
Provider Name (Legal Business Name): TOMMY VANCE RAY JR. DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 CAMDEN RD
PINE BLUFF AR
71603-9082
US

IV. Provider business mailing address

PO BOX 1306 3415 CAMDEN ROAD
PINE BLUFF AR
71613-1306
US

V. Phone/Fax

Practice location:
  • Phone: 870-879-4970
  • Fax: 870-879-6650
Mailing address:
  • Phone: 870-879-4970
  • Fax: 870-879-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1025
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: