Healthcare Provider Details

I. General information

NPI: 1669146346
Provider Name (Legal Business Name): THE PEDIATRIC CLINIC OF NLR, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203B PLAZA BLVD
CABOT AR
72023-3749
US

IV. Provider business mailing address

1525 COUNTRY CLUB RD
SHERWOOD AR
72120-5076
US

V. Phone/Fax

Practice location:
  • Phone: 501-843-0068
  • Fax: 501-843-0696
Mailing address:
  • Phone: 501-758-1530
  • Fax: 501-819-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TONYA SIMS
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 501-758-1530