1538358247 NPI number — FAYETTEVILLE PLASTIC SURGERY CLINIC

Table of content: (NPI 1538358247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538358247 NPI number — FAYETTEVILLE PLASTIC SURGERY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAYETTEVILLE PLASTIC SURGERY CLINIC
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:
PLASTIC SURGERY CLINIC OF NORTHWEST ARKANSAS
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:
1538358247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1794 E JOYCE BLVD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72703-5256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-443-7771
Provider Business Mailing Address Fax Number:
479-443-7790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1794 E JOYCE BLVD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-5256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-443-7771
Provider Business Practice Location Address Fax Number:
479-443-7790
Provider Enumeration Date:
10/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SANDLIN
Authorized Official First Name:
C
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
479-443-7771

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  R3739 , 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)





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