Healthcare Provider Details

I. General information

NPI: 1770933673
Provider Name (Legal Business Name): MISENHEIMER MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 OAKHURST BLVD
EL DORADO AR
71730-3736
US

IV. Provider business mailing address

117 OAKHURST BLVD
EL DORADO AR
71730-3736
US

V. Phone/Fax

Practice location:
  • Phone: 870-918-6684
  • Fax:
Mailing address:
  • Phone: 870-918-6684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License NumberA004788
License Number StateAR

VIII. Authorized Official

Name: MRS. AMBROSIA ALEXANDRA MISENHEIMER
Title or Position: OWNER/PRESIDENT
Credential: FNP-C
Phone: 870-918-6684