Healthcare Provider Details

I. General information

NPI: 1265439632
Provider Name (Legal Business Name): CONWAY ENDOSCOPY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 HOGAN LN
CONWAY AR
72034-8201
US

IV. Provider business mailing address

PO BOX 10780
CONWAY AR
72034-0013
US

V. Phone/Fax

Practice location:
  • Phone: 501-764-1960
  • Fax: 501-513-0798
Mailing address:
  • Phone: 501-764-1960
  • Fax: 501-513-0798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License NumberAR3956
License Number StateAR

VIII. Authorized Official

Name: KEVIN D HEATH
Title or Position: PRESIDENT
Credential: MD
Phone: 501-764-1960