1154041549 NPI number — MS. RAGON DAWN WEATHERFORD LAC

Table of content: MS. RAGON DAWN WEATHERFORD LAC (NPI 1154041549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154041549 NPI number — MS. RAGON DAWN WEATHERFORD LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEATHERFORD
Provider First Name:
RAGON
Provider Middle Name:
DAWN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCBRIDE
Provider Other First Name:
RAGON
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154041549
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1815 PLEASANT GROVE RD
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:
870-336-1339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 MORGAN ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
PARAGOULD
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72450-3949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-335-9483
Provider Business Practice Location Address Fax Number:
870-335-9487
Provider Enumeration Date:
08/29/2022

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: 101YM0800X , with the licence number:  A2208022 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com