1306975578 NPI number — MRS. CATHERINE L SHOURD OTRL

Table of content: MRS. CATHERINE L SHOURD OTRL (NPI 1306975578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306975578 NPI number — MRS. CATHERINE L SHOURD OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOURD
Provider First Name:
CATHERINE
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

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:
1306975578
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 AGARITA CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72032-8520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-329-4641
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 SOUTH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72034-6455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-329-8102
Provider Business Practice Location Address Fax Number:
501-329-2113
Provider Enumeration Date:
03/05/2007

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: 225XP0200X , with the licence number:  OTR1133 , 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: OTR1133 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com