Healthcare Provider Details

I. General information

NPI: 1972367670
Provider Name (Legal Business Name): ARKANSAS PAIN THERAPY MENA CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 CRESTWOOD CIR
MENA AR
71953-5513
US

IV. Provider business mailing address

5601 CAPTAINS LN
WILMINGTON NC
28409-3619
US

V. Phone/Fax

Practice location:
  • Phone: 479-234-4433
  • Fax: 479-234-4445
Mailing address:
  • Phone: 910-200-5238
  • Fax: 877-296-5238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK ADAMS
Title or Position: OWNER
Credential:
Phone: 479-234-4433