1841513223 NPI number — JACKIE COOMBE-MOORE PA

Table of content: (NPI 1841513223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841513223 NPI number — JACKIE COOMBE-MOORE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKIE COOMBE-MOORE PA
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:
CONWAY PSYCHIATRIC CENTER
Provider Other Organization Name Type Code:
3
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:
1841513223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
680 HOGAN LN
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:
72034-8131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-505-8900
Provider Business Mailing Address Fax Number:
501-505-8902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
680 HOGAN LN
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:
72034-8131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-505-8900
Provider Business Practice Location Address Fax Number:
501-505-8902
Provider Enumeration Date:
03/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COOMBE-MOORE
Authorized Official First Name:
JACKIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
501-505-8900

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11547000000 . This is a "QCA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 55779 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 122013001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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