Healthcare Provider Details

I. General information

NPI: 1083677728
Provider Name (Legal Business Name): ST.JOSEPH'S PET CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCY LANE SUITE 105
HOT SPRINGS AR
71913
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 877-223-3988
  • Fax: 479-968-4331
Mailing address:
  • Phone: 479-968-7930
  • Fax: 479-968-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KERRI COUCH
Title or Position: MANAGER
Credential:
Phone: 479-968-7930