Healthcare Provider Details

I. General information

NPI: 1134594229
Provider Name (Legal Business Name): RUSSELL B ALLISON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5395 W ASH ST STE 1
POTTSVILLE AR
72858-9228
US

IV. Provider business mailing address

PO BOX 1146
RUSSELLVILLE AR
72811-1146
US

V. Phone/Fax

Practice location:
  • Phone: 479-219-5034
  • Fax:
Mailing address:
  • Phone: 479-890-9292
  • Fax: 479-890-6962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: SABRINA PARIS TENCLEVE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 479-890-9292