Provider Demographics
NPI:1780321067
Name:ALEXANDER, COLEMAN
Entity type:Individual
Prefix:
First Name:COLEMAN
Middle Name:
Last Name:ALEXANDER
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 1:97 OTTO RD
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173-9422
Mailing Address - Country:US
Mailing Address - Phone:501-672-4188
Mailing Address - Fax:
Practice Address - Street 1:1108 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-4486
Practice Address - Country:US
Practice Address - Phone:501-672-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7765225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist