Healthcare Provider Details

I. General information

NPI: 1932114725
Provider Name (Legal Business Name): DEWITT FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 W 13TH ST
DEWITT AR
72042-3001
US

IV. Provider business mailing address

609 W 13TH ST PO BOX 607
DEWITT AR
72042-3001
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-1120
  • Fax: 870-946-1132
Mailing address:
  • Phone: 870-946-1120
  • Fax: 870-946-1132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberA01288ANP
License Number StateAR

VIII. Authorized Official

Name: DEBRA CHARLENE WEST
Title or Position: APN/OWNER
Credential: APN
Phone: 870-946-1120