Provider Demographics
NPI:1669668786
Name:SMALE, RAYMOND JOHN
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:JOHN
Last Name:SMALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 616
Mailing Address - Street 2:
Mailing Address - City:YELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72687-0616
Mailing Address - Country:US
Mailing Address - Phone:870-565-0960
Mailing Address - Fax:
Practice Address - Street 1:315 MC 6043
Practice Address - Street 2:
Practice Address - City:YELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72687-8494
Practice Address - Country:US
Practice Address - Phone:870-565-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR61179171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor