Provider Demographics
NPI:1134948896
Name:LOVE, VONTEI
Entity type:Individual
Prefix:
First Name:VONTEI
Middle Name:
Last Name:LOVE
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 1:305 SHIRLEY ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72417-8985
Mailing Address - Country:US
Mailing Address - Phone:870-926-8484
Mailing Address - Fax:
Practice Address - Street 1:305 SHIRLEY ST
Practice Address - Street 2:
Practice Address - City:BROOKLAND
Practice Address - State:AR
Practice Address - Zip Code:72417-8985
Practice Address - Country:US
Practice Address - Phone:870-926-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty