Healthcare Provider Details

I. General information

NPI: 1912679549
Provider Name (Legal Business Name): ITI CHITO ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E COLLIN RAYE DR STE 2
DE QUEEN AR
71832-8068
US

IV. Provider business mailing address

500 E. COLLIN RAYE DRIVE
DE QUEEN AR
71832-8054
US

V. Phone/Fax

Practice location:
  • Phone: 870-642-7257
  • Fax: 870-642-5015
Mailing address:
  • Phone: 870-642-7257
  • Fax: 870-642-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RUSTY LYNN GRIFFIN
Title or Position: OWNER
Credential:
Phone: 501-765-0275