Healthcare Provider Details

I. General information

NPI: 1386944791
Provider Name (Legal Business Name): NORTHWEST ARKANSAS IMMUNIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2719 SE I ST
BENTONVILLE AR
72712-3996
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 479-273-5437
  • Fax: 479-273-9932
Mailing address:
  • Phone: 479-968-4273
  • Fax: 479-968-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KIMBERLY L CADLE
Title or Position: AUTHORIZED OFFICIA-OWNER
Credential: MD
Phone: 479-273-5437