1477598795 NPI number — PEDIATRIC NUTRITION PROV OF AR

Table of content: (NPI 1477598795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477598795 NPI number — PEDIATRIC NUTRITION PROV OF AR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC NUTRITION PROV OF AR
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:
1477598795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
920 EDISON AVE
Provider Second Line Business Mailing Address:
STE 9
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72015-4502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 EDISON AVE
Provider Second Line Business Practice Location Address:
STE 9
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015-4502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-315-7337
Provider Business Practice Location Address Fax Number:
501-778-7488
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
LEONARD
Authorized Official Middle Name:
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
901-315-7337

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  AR20528 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 0422357 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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