1154705382 NPI number — JASON OTIS MOORE

Table of content: MADALEINE ANKELE LMT (NPI 1578165874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154705382 NPI number — JASON OTIS MOORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
JASON
Provider Middle Name:
OTIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1154705382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2607 CADDO ST. - STE. 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARKADELPHIA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71923-5307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-230-8217
Provider Business Mailing Address Fax Number:
870-230-8201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W. AVE E ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOPE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-773-0700
Provider Business Practice Location Address Fax Number:
870-773-0705
Provider Enumeration Date:
07/17/2015

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: 171M00000X , 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: 226648795 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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