Healthcare Provider Details

I. General information

NPI: 1134445422
Provider Name (Legal Business Name): CB KING EUDORA CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N MAIN ST
EUDORA AR
71640-3037
US

IV. Provider business mailing address

114 N MAIN ST
EUDORA AR
71640-3037
US

V. Phone/Fax

Practice location:
  • Phone: 870-501-1629
  • Fax: 870-222-4557
Mailing address:
  • Phone: 870-501-1629
  • Fax: 870-222-4557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number01923
License Number StateAR

VIII. Authorized Official

Name: SHERRY J. GREGORY
Title or Position: OFFICE MANAGER
Credential:
Phone: 870-222-4544