Healthcare Provider Details

I. General information

NPI: 1790867257
Provider Name (Legal Business Name): MAYFLOWER FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 HIGHWAY 365
MAYFLOWER AR
72106
US

IV. Provider business mailing address

PO BOX 925
MAYFLOWER AR
72106-0925
US

V. Phone/Fax

Practice location:
  • Phone: 501-470-7413
  • Fax: 501-470-7415
Mailing address:
  • Phone: 501-470-7413
  • Fax: 501-470-7415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS JANE A JACKSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 501-470-7413