Healthcare Provider Details

I. General information

NPI: 1841823200
Provider Name (Legal Business Name): THE GREGORY KISTLER TREATMENT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 S M ST
FORT SMITH AR
72903-2903
US

IV. Provider business mailing address

3304 S M ST
FORT SMITH AR
72903-2903
US

V. Phone/Fax

Practice location:
  • Phone: 479-785-4677
  • Fax: 479-785-4673
Mailing address:
  • Phone: 479-785-4677
  • Fax: 479-785-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER KISTLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 479-785-4677