Healthcare Provider Details

I. General information

NPI: 1679701213
Provider Name (Legal Business Name): MENA HEART AND VASCULAR CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 06/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 MORROW ST N SUITE G
MENA AR
71953-4324
US

IV. Provider business mailing address

PO BOX 295
LOCKESBURG AR
71846-0295
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-6100
  • Fax:
Mailing address:
  • Phone: 870-289-5865
  • Fax: 870-289-6993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberE5746
License Number StateAR

VIII. Authorized Official

Name: BOB ELLZEY
Title or Position: CEO
Credential:
Phone: 479-394-6100