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General NPI Number Information
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NPI Number | 1023314432
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Entity Type | Individual
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Provider Name | COREY MILLS PTA
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Gender | Male
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Dates
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Enumeration Date | 02/02/2011
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Last Update Date | 02/02/2011
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Provider Practice Location Address
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Address Line | 9880 BROCKINGTON RD SUITE 147
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City | SHERWOOD
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State | AR
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Zip | 72120-3585
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Country | US
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Telephone | 501-944-7819
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Fax |
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Provider Business Mailing Address
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Address Line | 22 VISTA DR
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City | LITTLE ROCK
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State | AR
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Zip | 72210-1720
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Country | US
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Telephone | 501-412-3509
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | PTA 1244
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License Number State | AR
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