Healthcare Provider Details

I. General information

NPI: 1346032208
Provider Name (Legal Business Name): PRESTIGE CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W WASHINGTON AVE STE B
JONESBORO AR
72401-2781
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 870-275-4272
  • Fax: 870-275-4277
Mailing address:
  • Phone: 800-824-4094
  • Fax: 479-968-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN WAGNER CARLYLE
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 479-498-6700