1033491519 NPI number — NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC.

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 1033491519 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:
Provider Other Organization Name Type Code:
6
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:
1033491519
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:
4909 EAST JOHNSON AVE.
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:
870-336-3372
Provider Business Practice Location Address Fax Number:
870-934-3658
Provider Enumeration Date:
09/12/2011

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12577 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 200341134 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com