Provider Demographics
NPI:1497878359
Name:ROSS, SEKETA S
Entity Type:Individual
Prefix:MRS
First Name:SEKETA
Middle Name:S
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-3318
Mailing Address - Country:US
Mailing Address - Phone:870-901-6150
Mailing Address - Fax:870-234-8663
Practice Address - Street 1:904 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-3318
Practice Address - Country:US
Practice Address - Phone:870-901-6150
Practice Address - Fax:870-234-8663
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor