Healthcare Provider Details

I. General information

NPI: 1407604572
Provider Name (Legal Business Name): 114 N PITTMAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N PITTMAN ST
PRAIRIE GROVE AR
72753-2934
US

IV. Provider business mailing address

14971 COVE CRK N
PRAIRIE GROVE AR
72753-8821
US

V. Phone/Fax

Practice location:
  • Phone: 479-846-4110
  • Fax:
Mailing address:
  • Phone: 630-699-6211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEC SPENCER
Title or Position: OWNER
Credential: DC
Phone: 630-699-6211