1447581673 NPI number — NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447581673 NPI number — NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, 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:
Provider Other Organization Name Type Code:
6
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:
1447581673
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 N HUMPHREYS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38120-2177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3005 MIDDLEFIELD DR
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:
72401-7438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-934-5102
Provider Business Practice Location Address Fax Number:
870-932-3608
Provider Enumeration Date:
01/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DUCKETT
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SR VP/ CLO
Authorized Official Telephone Number:
901-227-5233

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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