Healthcare Provider Details

I. General information

NPI: 1477348704
Provider Name (Legal Business Name): KEVIN MCCLELLAN RVS, RCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 GRISHAM RD
ROYAL AR
71968-9565
US

IV. Provider business mailing address

PO BOX 377
ROYAL AR
71968-0377
US

V. Phone/Fax

Practice location:
  • Phone: 501-276-6557
  • Fax:
Mailing address:
  • Phone: 501-276-6557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number00066276
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: