1043869019 NPI number — JOHNATHAN DANIEL BROWN QBHP

Table of content: BERNADETTE A SWIATKOWSKI P.T. (NPI 1407982069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043869019 NPI number — JOHNATHAN DANIEL BROWN QBHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
JOHNATHAN
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
QBHP
Provider Gender Code:
M

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:
1043869019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 PLEASANT GROVE ROAD
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:
72405-7870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-933-6886
Provider Business Mailing Address Fax Number:
870-933-9395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 HWY 62/412
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
ASH FLAT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72513-9629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-994-7060
Provider Business Practice Location Address Fax Number:
870-994-7063
Provider Enumeration Date:
09/11/2019

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: 171M00000X , 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: 235720795 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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