1336417336 NPI number — ARKANSAS PAIN AND WELLNESS, LLC

Table of content: (NPI 1336417336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336417336 NPI number — ARKANSAS PAIN AND WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARKANSAS PAIN AND WELLNESS, LLC
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:
1336417336
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4600 TOWSON AVE
Provider Second Line Business Mailing Address:
SUITE 101-W2
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72901-7961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-353-2904
Provider Business Mailing Address Fax Number:
479-763-3168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 TOWSON AVE
Provider Second Line Business Practice Location Address:
SUITE 101-W2
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72901-7961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-353-2904
Provider Business Practice Location Address Fax Number:
479-763-3168
Provider Enumeration Date:
12/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SEWELL
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
ANESTHESIOLOGIST-PAIN MEDICINE
Authorized Official Telephone Number:
479-353-2904

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  E6975 , 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)





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