Full Name | |
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Speciality | Clinic/Center |
Location | 233 N Main St, Portland, Arkansas |
Authorized Official Name and Position | Gary Allan Nichols (CEO) |
Authorized Official Contact | 8709423000 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Po Box 509 Dermott AR 71638-0509 Ph: (870) 942-3000 | 233 N Main St Portland AR 71663 Ph: (870) 737-2221 |
NPI Number | 1316106388 |
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Provider Enumeration Date | 06/05/2008 |
Last Update Date | 09/18/2024 |
Certification Date | 09/18/2024 |
Medicare PECOS PAC ID | 5193785590 |
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Medicare Enrollment ID | O20110502000760 |
Identifier | Type | State | Issuer |
---|---|---|---|
1316106388 | NPI | - | NPPES |
117615749 | Medicaid | AR |