Provider Demographics
NPI:1720092364
Name:FAVORITE, JUSTIN GREGORY (DC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GREGORY
Last Name:FAVORITE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:693 WHITE RD STE E
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-2918
Mailing Address - Country:US
Mailing Address - Phone:479-756-1155
Mailing Address - Fax:479-756-1130
Practice Address - Street 1:1127 S GUTENSOHN RD
Practice Address - Street 2:STE. 110
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-5228
Practice Address - Country:US
Practice Address - Phone:479-756-1155
Practice Address - Fax:479-756-1130
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1676111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1676OtherSTATE LISCENSE
AR47-5357469OtherTAX ID
AR47-5357469OtherTAX ID
AR194065718Medicaid