1033113741 NPI number — THE FAMILY CLINIC OF NASHVILLE, P.A.

Table of content: (NPI 1033113741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033113741 NPI number — THE FAMILY CLINIC OF NASHVILLE, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FAMILY CLINIC OF NASHVILLE, P.A.
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:
1033113741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71852-0549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-845-1933
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 LESLIE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71852-4027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-845-1933
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
JOE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
870-845-1933

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MC-0293 , 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: 56777 . This is a "BLUE CROSS OF ARKANSAS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 56777 . This is a "HEALTH ADVANTAGE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 14413000000 . This is a "QUALCHOICE OF ARKANSAS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 56777 . This is a "BLUE ADVANTAGE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: AR0001341 . This is a "TRICARE/HUMANA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 622147 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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