Healthcare Provider Details

I. General information

NPI: 1659319150
Provider Name (Legal Business Name): TRACY FAMILY PRACTICE CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 S WHITEHEAD DR
DE WITT AR
72042-2906
US

IV. Provider business mailing address

1940 S WHITEHEAD DR
DE WITT AR
72042-2906
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-4505
  • Fax: 870-946-2428
Mailing address:
  • Phone: 870-946-4505
  • Fax: 870-946-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberC7340
License Number StateAR

VIII. Authorized Official

Name: DR. WALLACE LEE TRACY
Title or Position: OWNER
Credential: M.D.
Phone: 870-946-4505