Provider Demographics
NPI:1972123636
Name:TRAN, DUC (DOUGLAS)
Entity type:Individual
Prefix:
First Name:DUC (DOUGLAS)
Middle Name:
Last Name:TRAN
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 1:116 NW APPLE BLOSSOM
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-8424
Mailing Address - Country:US
Mailing Address - Phone:479-936-1668
Mailing Address - Fax:
Practice Address - Street 1:1615 E CENTERTON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-9208
Practice Address - Country:US
Practice Address - Phone:479-936-1668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8424225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty