Basic Information
| Provider Information | |||||||||
| NPI: | 1518564616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RALLENS | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | |||||||||
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| Credential: | QBHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2885 W BATTLEFIELD ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658073952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615214 | ||||||||
| FaxNumber: | 4177615065 | ||||||||
| Practice Location | |||||||||
| Address1: | 3715 N BUSINESS DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727035204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795211532 | ||||||||
| FaxNumber: | 4795219940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2020 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 000 | AR | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.