MEDICARE: CHAFFEE DIAGNOSTICS 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
1	261QR0200X	Radiology Clinic/Center	E3907	AR

General Provider Information

NPI Number	:	1649715681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAFFEE DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	11300 ROBERTS BLVD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72916-6027
Country	:	US
Telephone Number	:	479-434-6205
Fax Number	:	479-434-6210

Provider Business Practice Location Address
First Line	:	11300 ROBERTS BLVD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72916-6027
Country	:	US
Telephone Number	:	479-434-6205
Fax Number	:	479-434-6210

Authorized Official
Title or Position	:	CHIEF OF STAFF
Name	:	WILLIAM J HAYES
Credential	:	MD
Telephone Number	:	479-434-5295

Provider Enumeration Date	:	12/29/2016
Last Update Date	:	12/29/2016

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