1053687178 NPI number — MR. KELLEY THOMAS WALTERS QBHP

Table of content: MR. KELLEY THOMAS WALTERS QBHP (NPI 1053687178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053687178 NPI number — MR. KELLEY THOMAS WALTERS QBHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTERS
Provider First Name:
KELLEY
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
QBHP
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:
1053687178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 PLEASANT GROVE ROAD
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:
72404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-933-6886
Provider Business Mailing Address Fax Number:
870-933-9395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1704 HWY. 69
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRUMANN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-483-4003
Provider Business Practice Location Address Fax Number:
870-483-4009
Provider Enumeration Date:
03/23/2012

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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