Healthcare Provider Details

I. General information

NPI: 1720723513
Provider Name (Legal Business Name): FAITH AND FAMILY MEDICAL PROVIDERS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 HIGHWAY 371 S
MAGNOLIA AR
71753-8960
US

IV. Provider business mailing address

363 HIGHWAY 371 S
MAGNOLIA AR
71753-8960
US

V. Phone/Fax

Practice location:
  • Phone: 573-202-4070
  • Fax:
Mailing address:
  • Phone: 479-310-5206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACQUELYN BLADDICK
Title or Position: HUMAN RESOURCES
Credential:
Phone: 479-310-5206