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NPI Code Detail

MEDICARE: 1621 E 42 LLC

MEDICARE: 1621 E 42 LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1251S00000XCommunity/Behavioral Health Agency

General Provider Information

NPI Number : 1437964244
Entity Type Code : Organization
Provider Name (Legal Business Name) : 1621 E 42 LLC
Provider Business Mailing Address
First Line : 10 SHACKLEFORD PLZ STE 102
Second Line :
City : LITTLE ROCK
State : AR
Zip : 72211-1886
Country : US
Telephone Number : 501-224-0846
Fax Number : 501-224-0834
Provider Business Practice Location Address
First Line : 1623 E 42ND ST
Second Line :
City : TEXARKANA
State : AR
Zip : 71854-1894
Country : US
Telephone Number : 870-772-0689
Fax Number :
Authorized Official
Title or Position : CEO/PRESIDENT
Name : MR. EDWARD V HOLMAN
Credential :
Telephone Number : 501-224-0846
Provider Enumeration Date : 02/10/2025
Last Update Date : 02/11/2026

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Directions to “1621 E 42 LLC ” Practice Location

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