Healthcare Provider Details

I. General information

NPI: 1528039088
Provider Name (Legal Business Name): LANCE EDWARD VESTAL OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 W CHESTNUT ST
ROGERS AR
72756
US

IV. Provider business mailing address

908 NW 8TH ST
BENTONVILLE AR
72712
US

V. Phone/Fax

Practice location:
  • Phone: 479-631-3955
  • Fax: 479-631-0152
Mailing address:
  • Phone: 479-273-1141
  • Fax: 479-273-3762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR987
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: