1528213642 NPI number — CRESTPARK DEWITT, LLC

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 1528213642 NPI number — CRESTPARK DEWITT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTPARK DEWITT, LLC
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:
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:
1528213642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 589
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DE WITT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72042-0589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-946-3569
Provider Business Mailing Address Fax Number:
870-946-0699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 LIBERTY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DE WITT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72042-3430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-946-3569
Provider Business Practice Location Address Fax Number:
870-946-0699
Provider Enumeration Date:
11/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DILKS
Authorized Official First Name:
MELISHA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
870-821-0144

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  637 , 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: 015177 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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