Provider Demographics
NPI:1255560793
Name:CANTRELL, CHARLES RICHARD JR (LMT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
Last Name:CANTRELL
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E CRANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-3629
Mailing Address - Country:US
Mailing Address - Phone:870-704-4072
Mailing Address - Fax:870-743-9881
Practice Address - Street 1:105 E CRANDALL AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3629
Practice Address - Country:US
Practice Address - Phone:870-704-4072
Practice Address - Fax:870-743-9881
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6608172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist