1689021420 NPI number — BOYETTE FACIAL PLASTIC SURGERY, PA

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 1689021420 NPI number — BOYETTE FACIAL PLASTIC SURGERY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOYETTE FACIAL PLASTIC SURGERY, PA
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:
1689021420
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 241212
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72223-0004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-205-8610
Provider Business Mailing Address Fax Number:
501-205-8610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9601 LILE DR.
Provider Second Line Business Practice Location Address:
MEDICAL TOWERS BUILDING 1, SUITE 970B
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205-6321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-205-8610
Provider Business Practice Location Address Fax Number:
501-205-8610
Provider Enumeration Date:
05/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BOYETTE
Authorized Official First Name:
JENNINGS
Authorized Official Middle Name:
RUSSELL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
501-205-8610

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  E-7894 , 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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