1962896217 NPI number — MADELINE NOEL FULTS CIT

Table of content: (NPI 1184891178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962896217 NPI number — MADELINE NOEL FULTS CIT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULTS
Provider First Name:
MADELINE
Provider Middle Name:
NOEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CIT
Provider Gender Code:
F

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:
1962896217
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE HALL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71612-1203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-247-5222
Provider Business Mailing Address Fax Number:
870-671-4847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2304 W 29TH AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PINE BLUFF
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71603-5005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-247-5222
Provider Business Practice Location Address Fax Number:
870-671-4847
Provider Enumeration Date:
03/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 206621740 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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