1871688663 NPI number — MRS. DEZRA J EICHHORN APN

Table of content: MRS. DEZRA J EICHHORN APN (NPI 1871688663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871688663 NPI number — MRS. DEZRA J EICHHORN APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EICHHORN
Provider First Name:
DEZRA
Provider Middle Name:
J
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

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:
1871688663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1144
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEARCY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-230-9181
Provider Business Mailing Address Fax Number:
501-268-0134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 S. MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SEARCY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-230-9181
Provider Business Practice Location Address Fax Number:
501-268-0134
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  A01585 , 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: 179293758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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