1750550489 NPI number — FOOT CARE OF NORTHEAST ARKANSAS PA

Table of content: (NPI 1750550489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750550489 NPI number — FOOT CARE OF NORTHEAST ARKANSAS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT CARE OF NORTHEAST ARKANSAS 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:
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:
1750550489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1984
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72403-1984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-933-8900
Provider Business Mailing Address Fax Number:
870-933-2611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 E WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401-3108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-933-8900
Provider Business Practice Location Address Fax Number:
870-933-2611
Provider Enumeration Date:
02/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CALDWELL
Authorized Official First Name:
EDDY
Authorized Official Middle Name:
LLOYD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-933-8900

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  AR163 , 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: 16888000000 . This is a "QUALCHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 167681748 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480034780 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5F963 . This is a "MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5T344 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 130246748 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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