1972808145 NPI number — CONWAY PSYCHIATRIC CLINIC, PLLC

Table of content: (NPI 1972808145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972808145 NPI number — CONWAY PSYCHIATRIC CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONWAY PSYCHIATRIC CLINIC, PLLC
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:
1972808145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10705
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72034-0012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-472-7697
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5330 PLANTATION CV
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72034-8586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-472-7697
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
HARLECH
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
501-472-7697

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  C-8236 , 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: 129952001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com