1982141149 NPI number — IM A 10 WELLNESS CENTER, LLC

Table of content: DR. STEVEN LEE REGAN DDS (NPI 1518980010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982141149 NPI number — IM A 10 WELLNESS CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IM A 10 WELLNESS CENTER, LLC
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:
1982141149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
404 LAKE WOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEARCY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72143-9056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-593-6997
Provider Business Mailing Address Fax Number:
501-325-2912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 LAKE WOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEARCY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72143-9056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-593-6997
Provider Business Practice Location Address Fax Number:
501-325-2912
Provider Enumeration Date:
01/26/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCCARROLL
Authorized Official First Name:
SHIVONNE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
501-593-6997

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  5940-C , 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)