Healthcare Provider Details

I. General information

NPI: 1114771920
Provider Name (Legal Business Name): THE RAY DAE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2024
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 MADISON DR
PRAIRIE GROVE AR
72753-2871
US

IV. Provider business mailing address

701 MADISON DR
PRAIRIE GROVE AR
72753-2871
US

V. Phone/Fax

Practice location:
  • Phone: 479-715-3875
  • Fax:
Mailing address:
  • Phone: 479-715-3875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER JANE COOK
Title or Position: OWNER
Credential: MS, SDP, CHC
Phone: 479-715-3875