Healthcare Provider Details

I. General information

NPI: 1679722664
Provider Name (Legal Business Name): CITY OF TUCKERMAN RECORDER TREASURER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MAIN STREET
TUCKERMAN AR
72473-0779
US

IV. Provider business mailing address

PO BOX 641880
OMAHA NE
68164-7880
US

V. Phone/Fax

Practice location:
  • Phone: 870-349-5212
  • Fax:
Mailing address:
  • Phone: 402-572-4019
  • Fax: 402-991-0719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number239
License Number StateAR

VIII. Authorized Official

Name: WROTEN S KOLLER
Title or Position: CHIEF
Credential: CHIEF
Phone: 870-349-5212