Individual
KYOKO PROVENCIO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
136 GREGORY PL, JACKSONVILLE, AR 72076-3212
(501) 412-4536
Mailing address
136 GREGORY PL, JACKSONVILLE, AR 72076-3212
(501) 412-4536
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
7773
AR
Other
Enumeration date
02/19/2020
Last updated
02/19/2020
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