1013274364 NPI number — SERVANT HEALTHCARE, PA

Table of content: (NPI 1013274364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013274364 NPI number — SERVANT HEALTHCARE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERVANT HEALTHCARE, PA
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:
APEX MEN'S HEALTH
Provider Other Organization Name Type Code:
3
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:
1013274364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10700 N RODNEY PARHAM ROAD
Provider Second Line Business Mailing Address:
STE C-10A
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-246-7274
Provider Business Mailing Address Fax Number:
501-421-4161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10700 N RODNEY PARHAM ROAD
Provider Second Line Business Practice Location Address:
STE C-10A
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-246-7274
Provider Business Practice Location Address Fax Number:
501-421-4161
Provider Enumeration Date:
04/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WARFORD
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
501-920-2252

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  BL00123175 , 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)

  • Identifier: 5GB23 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com