Provider Demographics
NPI:1538674270
Name:REGO, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:REGO
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 1:5400 EUPER LN
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3232
Mailing Address - Country:US
Mailing Address - Phone:870-932-3600
Mailing Address - Fax:
Practice Address - Street 1:5400 EUPER LN
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3232
Practice Address - Country:US
Practice Address - Phone:870-932-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No174400000XOther Service ProvidersSpecialist