1962719856 NPI number — LITTLE RIVER MEDICAL CENTER, INC.

Table of content: (NPI 1962719856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962719856 NPI number — LITTLE RIVER MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITTLE RIVER MEDICAL CENTER, 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:
MEMORIAL MEDICAL 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:
1962719856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 W LOCKE ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ASHDOWN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71822-3326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-898-5011
Provider Business Mailing Address Fax Number:
870-898-4172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHDOWN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71822-2750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-898-4100
Provider Business Practice Location Address Fax Number:
870-898-5791
Provider Enumeration Date:
09/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KEENER
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
ADM. ASSISTANT
Authorized Official Telephone Number:
870-898-5011

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5G384 . This is a "BCS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 191446002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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