Healthcare Provider Details

I. General information

NPI: 1376517177
Provider Name (Legal Business Name): NORTHEAST ARKANSAS CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 GRANT AVE.
JONESBORO AR
72401
US

IV. Provider business mailing address

P.O. BOX 1960
JONESBORO AR
72403-1960
US

V. Phone/Fax

Practice location:
  • Phone: 870-934-5101
  • Fax: 870-932-3608
Mailing address:
  • Phone: 870-934-5101
  • Fax: 870-932-3608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERROL SCOT DAVIS
Title or Position: CFO
Credential:
Phone: 870-934-5803