Provider Demographics
NPI:1255038436
Name:SMALL, VAN R JR
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:R
Last Name:SMALL
Suffix:JR
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 1:322 TERRIO DR
Mailing Address - Street 2:
Mailing Address - City:RESERVE
Mailing Address - State:LA
Mailing Address - Zip Code:70084-6515
Mailing Address - Country:US
Mailing Address - Phone:504-559-4725
Mailing Address - Fax:
Practice Address - Street 1:322 TERRIO DR
Practice Address - Street 2:
Practice Address - City:RESERVE
Practice Address - State:LA
Practice Address - Zip Code:70084-6515
Practice Address - Country:US
Practice Address - Phone:504-559-4725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company