1770899122 NPI number — OUT OF KNOWHERE PLLC

Table of content: (NPI 1770899122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770899122 NPI number — OUT OF KNOWHERE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUT OF KNOWHERE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1770899122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3902 S FIR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE BLUFF
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71603-6233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-329-9626
Provider Business Mailing Address Fax Number:
870-534-5912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 DOLLARWAY RD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
WHITE HALL
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71602-3027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-329-9626
Provider Business Practice Location Address Fax Number:
870-534-5912
Provider Enumeration Date:
08/24/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WATTS
Authorized Official First Name:
CEDRIC
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
870-329-9626

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  6052 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OTR 1983 , 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)