Healthcare Provider Details

I. General information

NPI: 1801245105
Provider Name (Legal Business Name): YOUTH BRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5327 CRESTWOOD ST
HARRISON AR
72601-9292
US

IV. Provider business mailing address

5327 CRESTWOOD ST
HARRISON AR
72601-9292
US

V. Phone/Fax

Practice location:
  • Phone: 870-688-9651
  • Fax:
Mailing address:
  • Phone: 870-688-9651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number171M00000X
License Number StateAR

VIII. Authorized Official

Name: MRS. MARILYN HOKE
Title or Position: MHP
Credential:
Phone: 479-575-9471