1922476571 NPI number — TMJ AND FACIAL PAIN CENTER,LLC

Table of content: (NPI 1922476571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922476571 NPI number — TMJ AND FACIAL PAIN CENTER,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TMJ AND FACIAL PAIN CENTER,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:
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:
1922476571
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 BROWNS LANE
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-932-7000
Provider Business Mailing Address Fax Number:
870-932-1650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 BROWNS LANE
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-932-7000
Provider Business Practice Location Address Fax Number:
870-932-1650
Provider Enumeration Date:
09/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SOUTHARD
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
BOND
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
870-932-7000

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3469 , 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)





Copyright © 2007-2025 www.npivalidator.com