Healthcare Provider Details

I. General information

NPI: 1508036146
Provider Name (Legal Business Name): JOHNNY L. BOWMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N MAIN ST STE 3
NASHVILLE AR
71852-2000
US

IV. Provider business mailing address

410 N MAIN ST STE 3
NASHVILLE AR
71852-2000
US

V. Phone/Fax

Practice location:
  • Phone: 870-845-3725
  • Fax: 870-845-3322
Mailing address:
  • Phone: 870-845-3725
  • Fax: 870-845-3322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number2365
License Number StateAR

VIII. Authorized Official

Name: MRS. SHELLY PERRIN
Title or Position: SECRETARY
Credential:
Phone: 870-845-3725