Healthcare Provider Details

I. General information

NPI: 1831220334
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 PINE ST
ARKADELPHIA AR
71923-4335
US

IV. Provider business mailing address

141 GRISHAM RD
ROYAL AR
71968-9563
US

V. Phone/Fax

Practice location:
  • Phone: 870-245-2210
  • Fax:
Mailing address:
  • Phone: 501-282-2750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberP0607039
License Number StateAR

VIII. Authorized Official

Name: MR. LARRY LAMAR GRANT
Title or Position: MENTAL HEALTH PROFESSIONAL
Credential: LPC
Phone: 870-245-2210