Healthcare Provider Details

I. General information

NPI: 1508067331
Provider Name (Legal Business Name): TEXARKANA KIDNEY DISEASE & HYPERTENSION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 BEECH ST
TEXARKANA AR
71854-5310
US

IV. Provider business mailing address

422 BEECH ST
TEXARKANA AR
71854-5310
US

V. Phone/Fax

Practice location:
  • Phone: 870-773-1111
  • Fax: 870-772-7692
Mailing address:
  • Phone: 870-773-1111
  • Fax: 870-772-7692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MIKE BLANKENSHIP
Title or Position: PRESIDENT
Credential: MD
Phone: 870-773-1111