Healthcare Provider Details

I. General information

NPI: 1225202518
Provider Name (Legal Business Name): PREMISE HEALTH OF ARKANSAS MEDICAL P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MCKEE DR
GENTRY AR
72734-8761
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 479-326-8670
  • Fax: 479-326-8671
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER J VASQUEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 844-407-7557