1649784562 NPI number — DR Q PAIN & SPINE CLINIC, PA

Table of content: (NPI 1649784562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649784562 NPI number — DR Q PAIN & SPINE CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR Q PAIN & SPINE CLINIC, PA
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:
1649784562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 W MARKHAM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72205-3328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-227-0184
Provider Business Mailing Address Fax Number:
501-251-1975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 JOHN HARDEN DR STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72076-3786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-227-0184
Provider Business Practice Location Address Fax Number:
501-251-1975
Provider Enumeration Date:
11/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WELCH
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
501-227-0184

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 179747002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com