Healthcare Provider Details

I. General information

NPI: 1942346473
Provider Name (Legal Business Name): MICHAEL MARTIN OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 02/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 SMACKOVER HWY
SMACKOVER AR
71762-9533
US

IV. Provider business mailing address

1098 OLD STRONG HWY
STRONG AR
71765-9560
US

V. Phone/Fax

Practice location:
  • Phone: 870-725-2497
  • Fax: 870-725-2517
Mailing address:
  • Phone: 870-797-7802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTR1447
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: