1043332612 NPI number — SPA, INC.

Table of content: (NPI 1043332612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043332612 NPI number — SPA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPA, 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:
SENSATIONAL KIDS
Provider Other Organization Name Type Code:
5
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:
1043332612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3423 E HIGHLAND DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401-6404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-336-0021
Provider Business Mailing Address Fax Number:
870-336-0022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3423 E HIGHLAND DR STE A
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:
72401-6404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-336-0021
Provider Business Practice Location Address Fax Number:
870-336-0022
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MALONE
Authorized Official First Name:
LORI
Authorized Official Middle Name:
R
Authorized Official Title or Position:
SPEECH LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
870-336-0021

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  1842 , 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: 157521742 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145524721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145811721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 148112721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142244721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 152429721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145699721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157682721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161331721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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