Healthcare Provider Details

I. General information

NPI: 1407819840
Provider Name (Legal Business Name): ST.BERNARDS PET CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E JACKSON AVE
JONESBORO AR
72401-3119
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 877-223-3988
  • Fax:
Mailing address:
  • Phone: 479-968-7930
  • Fax: 479-968-1673

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: RODNEY THOMASON
Title or Position: MANAGER
Credential:
Phone: 479-968-7930