Healthcare Provider Details

I. General information

NPI: 1871953331
Provider Name (Legal Business Name): DAVID MANN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 FOXWOOD LN
WARD AR
72176-9448
US

IV. Provider business mailing address

117 FOXWOOD LN
WARD AR
72176-9448
US

V. Phone/Fax

Practice location:
  • Phone: 501-605-6103
  • Fax:
Mailing address:
  • Phone: 501-605-6103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOT-A1008
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT-A1008
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: