1982856126 NPI number — STONEYBROOK HEALTH SERVICES

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 1982856126 NPI number — STONEYBROOK HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONEYBROOK HEALTH SERVICES
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:
1982856126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2908 HAWKINS 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:
72143-4802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-305-3153
Provider Business Mailing Address Fax Number:
501-279-3695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 MILITARY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015-2581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-778-8282
Provider Business Practice Location Address Fax Number:
501-778-1232
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WIGGINS
Authorized Official First Name:
JOEY
Authorized Official Middle Name:
MARTIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
501-305-3153

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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)

  • Identifier: 174636311 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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