1336122340 NPI number — OTTER CREEK FAMILY CLINIC PLLC

Table of content: (NPI 1336122340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336122340 NPI number — OTTER CREEK FAMILY CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OTTER CREEK FAMILY CLINIC PLLC
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:
1336122340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11321 INTERSTATE 30
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72209-7059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-455-1331
Provider Business Mailing Address Fax Number:
501-455-5597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11321 INTERSTATE 30
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72209-7059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-455-1331
Provider Business Practice Location Address Fax Number:
501-455-5597
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ALEXANDER
Authorized Official First Name:
RITA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BILLING COORDINATOR
Authorized Official Telephone Number:
501-455-1331

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  C5502 , 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: 140671002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG8625 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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