Healthcare Provider Details

I. General information

NPI: 1689883209
Provider Name (Legal Business Name): SUPERIOR SOURCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 WESTMINISTER DR
LITTLE ROCK AR
72209-2949
US

IV. Provider business mailing address

78 WESTMINISTER DR
LITTLE ROCK AR
72209-2949
US

V. Phone/Fax

Practice location:
  • Phone: 501-568-4785
  • Fax: 501-562-0603
Mailing address:
  • Phone: 501-568-4785
  • Fax: 501-562-0603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: MR. VERNON OLANDUS JORDAN
Title or Position: PRESIDENT
Credential:
Phone: 501-568-4785