1538410147 NPI number — SALINE PHYSICIAN SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538410147 NPI number — SALINE PHYSICIAN SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALINE PHYSICIAN SERVICES, 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:
HEALTHY AGING CENTER
Provider Other Organization Name Type Code:
3
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:
1538410147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72018-2577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-776-6252
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015-3729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-574-7400
Provider Business Practice Location Address Fax Number:
501-574-7401
Provider Enumeration Date:
09/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TITSWORTH
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PHYSICIAN SERVICES
Authorized Official Telephone Number:
501-776-6093

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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