Healthcare Provider Details

I. General information

NPI: 1568643005
Provider Name (Legal Business Name): SGOH ACQUISITION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 JACKSON ST SW
GRAVETTE AR
72736-9121
US

IV. Provider business mailing address

1101 JACKSON ST SW
GRAVETTE AR
72736-9121
US

V. Phone/Fax

Practice location:
  • Phone: 479-787-5291
  • Fax: 479-344-6404
Mailing address:
  • Phone: 479-787-5291
  • Fax: 417-832-9041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberAR4517
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberAR4517
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC0050X
TaxonomyCritical Access Hospital Clinic/Center
License NumberAR4517
License Number StateAR
# 5
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number State

VIII. Authorized Official

Name: PAUL GREGORY TAYLOR
Title or Position: ADMINISTRATOR/CEO
Credential:
Phone: 417-837-2000