1134594229 NPI number — RUSSELL B ALLISON

Table of content: (NPI 1134594229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134594229 NPI number — RUSSELL B ALLISON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSSELL B ALLISON
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:
1134594229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1146
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72811-1146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-890-9292
Provider Business Mailing Address Fax Number:
479-890-6962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5395 W ASH ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POTTSVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72858-9228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-219-5034
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
TENCLEVE
Authorized Official First Name:
SABRINA
Authorized Official Middle Name:
PARIS
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
479-890-9292

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04D2089584 . This is a "CLIA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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