1801127030 NPI number — NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC.

Table of content: (NPI 1801127030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801127030 NPI number — NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, 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:
NEA BAPTIST 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:
1801127030
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 N HUMPHREYS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38120-2177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-227-5233
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4802 E. JOHNSON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-936-8000
Provider Business Practice Location Address Fax Number:
870-932-3608
Provider Enumeration Date:
01/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DUCKETT
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VP/ CLO
Authorized Official Telephone Number:
901-227-5233

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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