1679581532 NPI number — LEE COUNTY COOPERATIVE CLINIC

Table of content: (NPI 1679581532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679581532 NPI number — LEE COUNTY COOPERATIVE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEE COUNTY COOPERATIVE 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:
MADISON SATELLITE CLINIC
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:
1679581532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 669
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIANNA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72360-0669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-295-5225
Provider Business Mailing Address Fax Number:
870-295-6900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-295-5225
Provider Business Practice Location Address Fax Number:
870-295-6900
Provider Enumeration Date:
08/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
OSSIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CASHIER BILLING SUPERVISOR
Authorized Official Telephone Number:
870-295-5225

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 125273749 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".