Healthcare Provider Details

I. General information

NPI: 1649396979
Provider Name (Legal Business Name): FORREST CITY FAMILY PRACTICE CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 HOLIDAY DR SUITE 101
FORREST CITY AR
72335-9183
US

IV. Provider business mailing address

902 HOLIDAY DR SUITE 101
FORREST CITY AR
72335-9183
US

V. Phone/Fax

Practice location:
  • Phone: 870-630-1256
  • Fax:
Mailing address:
  • Phone: 870-630-1256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberR3762
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberR3762
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberR3762
License Number StateAR

VIII. Authorized Official

Name: NEIDA BYRD
Title or Position: BILLING MANAGER
Credential:
Phone: 901-737-3071