Healthcare Provider Details

I. General information

NPI: 1225289978
Provider Name (Legal Business Name): OUACHITA FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 DEQUEEN ST
MENA AR
71953-4132
US

IV. Provider business mailing address

PO BOX 1788
MENA AR
71953-1781
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-5068
  • Fax: 479-394-5626
Mailing address:
  • Phone: 479-394-5068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03080ANP
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN6236
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA01300-ANP
License Number StateAR

VIII. Authorized Official

Name: DEBBIE KINCAID
Title or Position: PRACTICE MANAGER
Credential:
Phone: 479-394-5068