Provider Demographics
NPI:1780242727
Name:BUSH, GREGORY LANCE
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:LANCE
Last Name:BUSH
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 11818
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1818
Mailing Address - Country:US
Mailing Address - Phone:479-452-6650
Mailing Address - Fax:479-452-5847
Practice Address - Street 1:HWY 23 N & 980 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AR
Practice Address - Zip Code:72949-3611
Practice Address - Country:US
Practice Address - Phone:479-785-9450
Practice Address - Fax:479-452-5847
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator