Healthcare Provider Details

I. General information

NPI: 1104356419
Provider Name (Legal Business Name): DE QUEEN MEDICAL CENTER DIALYSIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 W COLLIN RAYE DR
DE QUEEN AR
71832-2502
US

IV. Provider business mailing address

1306 W COLLIN RAYE DR
DE QUEEN AR
71832-2502
US

V. Phone/Fax

Practice location:
  • Phone: 870-584-4111
  • Fax: 870-584-4100
Mailing address:
  • Phone: 870-584-4111
  • Fax: 870-584-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JERRAMY ICENHOWER
Title or Position: ADMINISTRATOR
Credential:
Phone: 870-584-0272