1003110420 NPI number — JOSHUA PURSIFULL M.S. L.A.C.

Table of content: JOSHUA PURSIFULL M.S. L.A.C. (NPI 1003110420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003110420 NPI number — JOSHUA PURSIFULL M.S. L.A.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PURSIFULL
Provider First Name:
JOSHUA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S. L.A.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003110420
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2578
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATESVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72503-2578
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-793-8900
Provider Business Mailing Address Fax Number:
870-793-8959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1716 W SEARCY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEBER SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72543-3532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-793-8900
Provider Business Practice Location Address Fax Number:
870-793-8959
Provider Enumeration Date:
12/28/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  A1103025 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)