1770784886 NPI number — RUTHIE GIBSON

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770784886 NPI number — RUTHIE GIBSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUTHIE GIBSON
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:
1770784886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1207 W BLOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL DORADO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71730-5355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 W BLOCK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL DORADO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71730-5355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-864-5133
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
BOB
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERINDENT
Authorized Official Telephone Number:
870-864-5001

Provider Taxonomy Codes

  • Taxonomy code: 251300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 145351721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com