1588672638 NPI number — THE MENTAL FITNESS CENTER OF THE OZARKS,INC

Table of content: (NPI 1588672638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588672638 NPI number — THE MENTAL FITNESS CENTER OF THE OZARKS,INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MENTAL FITNESS CENTER OF THE OZARKS,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:
HARRIS AND ASSOCIATES
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:
1588672638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 SAINT ANDREWS CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIDEAWAY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75771-5056
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:
715 W SHERMAN AVE
Provider Second Line Business Practice Location Address:
STE F
Provider Business Practice Location Address City Name:
HARRISON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72601-2743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-577-2830
Provider Business Practice Location Address Fax Number:
871-741-3457
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-577-2830

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  76 19P , 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: 101734719 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 56201 . This is a "BLUE CROSS IDENTIFIER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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