Healthcare Provider Details

I. General information

NPI: 1255771531
Provider Name (Legal Business Name): ARKANSAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 W 6TH AVE
PINE BLUFF AR
71601-4136
US

IV. Provider business mailing address

2011 HILLSBOROUGH LN
LITTLE ROCK AR
72212-3730
US

V. Phone/Fax

Practice location:
  • Phone: 501-690-1328
  • Fax: 501-562-0327
Mailing address:
  • Phone: 501-690-1328
  • Fax: 501-562-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANA RENE FOLEY
Title or Position: MANAGING MEMBER
Credential:
Phone: 501-690-1328