Healthcare Provider Details

I. General information

NPI: 1376519454
Provider Name (Legal Business Name): SALEM FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 N MAIN ST
SALEM AR
72576-9449
US

IV. Provider business mailing address

PO BOX 829
SALEM AR
72576-0829
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-2541
  • Fax: 870-895-2957
Mailing address:
  • Phone: 870-895-2541
  • Fax: 870-895-2957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMC0433
License Number StateAR

VIII. Authorized Official

Name: DR. MICHAEL N MOODY
Title or Position: MEDICAL DOCTOR
Credential:
Phone: 870-895-2541