Healthcare Provider Details

I. General information

NPI: 1821225590
Provider Name (Legal Business Name): PEDIATRICS PLUS DIAGNOSTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 COLLEGE AVE
CONWAY AR
72034-6141
US

IV. Provider business mailing address

2740 COLLEGE AVE
CONWAY AR
72034-6141
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-5459
  • Fax: 501-327-1738
Mailing address:
  • Phone: 501-329-5459
  • Fax: 501-327-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMY DENTON
Title or Position: OWNER
Credential:
Phone: 501-329-5459