Healthcare Provider Details

I. General information

NPI: 1245035971
Provider Name (Legal Business Name): OLIVE BRANCH RECOVERY-ARKANSAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6028 W STONEY BROOK RD STE 3
ROGERS AR
72758-8180
US

IV. Provider business mailing address

6028 W STONEY BROOK RD STE 3
ROGERS AR
72758-8180
US

V. Phone/Fax

Practice location:
  • Phone: 940-220-8899
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JACOB MUMM
Title or Position: OWNER
Credential:
Phone: 940-220-8899