Healthcare Provider Details

I. General information

NPI: 1508675612
Provider Name (Legal Business Name): CARLYLE CARE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 E MILLSAP RD STE 107
FAYETTEVILLE AR
72703-4862
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 479-480-7150
  • Fax: 479-968-1673
Mailing address:
  • Phone: 800-824-4094
  • Fax: 479-968-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN WAGNER CARLYLE
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 479-498-6700