| |
4206 Frazier Pike College Station AR 72053 | |
(501) 490-2440 | |
(501) 490-0156 |
Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 4206 Frazier Pike, College Station, Arkansas |
Authorized Official Name and Position | Larnell W Davis (EXECUTIVE DIRECTOR) |
Authorized Official Contact | 8705432380 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
Po Box 1285 Pine Bluff AR 71613-1285 Ph: (870) 543-2380 | 4206 Frazier Pike College Station AR 72053 Ph: (501) 490-2440 |
NPI Number | 1932305737 |
---|---|
Provider Enumeration Date | 06/27/2007 |
Last Update Date | 07/20/2007 |
Medicare PECOS PAC ID | 5193634509 |
---|---|
Medicare Enrollment ID | O20100614000227 |
Identifier | Type | State | Issuer |
---|---|---|---|
1932305737 | NPI | - | NPPES |
122642749 | Medicaid | AR |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |