Healthcare Provider Details

I. General information

NPI: 1174826499
Provider Name (Legal Business Name): CENTER FOR PEDIATRIC NEUROSCIENCE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 FOX MEADOW LN
JONESBORO AR
72404-9346
US

IV. Provider business mailing address

PO BOX 814
WALNUT RIDGE AR
72476-0814
US

V. Phone/Fax

Practice location:
  • Phone: 870-932-4245
  • Fax:
Mailing address:
  • Phone: 901-603-9936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number11-16P
License Number StateAR

VIII. Authorized Official

Name: MR. JOB D CASPALL
Title or Position: BUSINESS MANAGER
Credential: M.B.A.
Phone: 901-603-9936