1043213093 NPI number — HOME I V SPECIALISTS INC

Table of content: (NPI 1043213093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043213093 NPI number — HOME I V SPECIALISTS INC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
HOME I V SPECIALISTS INC
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:
HOME IV SPECIALISTS INC
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:
1043213093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4222 PAYSPHERE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60674-0042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-972-1677
Provider Business Mailing Address Fax Number:
870-972-1911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-972-1677
Provider Business Practice Location Address Fax Number:
870-972-1911
Provider Enumeration Date:
05/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BERMAN
Authorized Official First Name:
CLIFFORD
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
800-879-6137

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: AR19641 , 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: 1989453 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 608170106 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130711047 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145490407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".