Healthcare Provider Details

I. General information

NPI: 1073719423
Provider Name (Legal Business Name): SOUTH ARKANSAS OPEN MRI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W HILLSBORO ST
EL DORADO AR
71730-6815
US

IV. Provider business mailing address

11101 HEFNER POINTE DR STE 218
OKLAHOMA CITY OK
73120-5054
US

V. Phone/Fax

Practice location:
  • Phone: 870-862-4624
  • Fax:
Mailing address:
  • Phone: 405-418-2900
  • Fax: 405-418-2200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEREK M PRENTICE
Title or Position: MANAGING MEMBER
Credential:
Phone: 405-418-2200