Healthcare Provider Details

I. General information

NPI: 1760440226
Provider Name (Legal Business Name): INTEGRATED COMMUNITY CLINICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101-2 N PROGRESS AVENUE
SILOAM SPRINGS AR
72761-4343
US

IV. Provider business mailing address

1101-2 N PROGRESS AVENUE PO BOX 1374
SILOAM SPRINGS AR
72761-1374
US

V. Phone/Fax

Practice location:
  • Phone: 479-549-3079
  • Fax: 479-549-3275
Mailing address:
  • Phone: 479-549-3079
  • Fax: 479-549-3275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY CHAMBERS
Title or Position: BILLING MANAGER
Credential:
Phone: 479-549-3079