1467485680 NPI number — TEXARKANA BEHAVIORAL ASSOCIATES LC

Table of content: (NPI 1467485680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467485680 NPI number — TEXARKANA BEHAVIORAL ASSOCIATES LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXARKANA BEHAVIORAL ASSOCIATES LC
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:
VISTA HEALTH TEXARKANA
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:
1467485680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4253 N CROSSOVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72703-4593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-521-5731
Provider Business Mailing Address Fax Number:
479-521-4926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 ARKANSAS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71854-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-521-5731
Provider Business Practice Location Address Fax Number:
479-521-4926
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FARLEY
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT & SECRETARY
Authorized Official Telephone Number:
615-861-6000

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  PENDING , 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: PENDING , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: PENDING , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: PENDING . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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