Healthcare Provider Details

I. General information

NPI: 1003869991
Provider Name (Legal Business Name): FAYETTEVILLE VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 PHOENIX AVE
FORT SMITH AR
72903-6073
US

IV. Provider business mailing address

PO BOX 94494
CLEVELAND OH
44101
US

V. Phone/Fax

Practice location:
  • Phone: 615-355-3451
  • Fax:
Mailing address:
  • Phone: 615-355-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN POTTER
Title or Position: NPI TEAM MEMBER
Credential:
Phone: 202-382-2579