Healthcare Provider Details

I. General information

NPI: 1386743482
Provider Name (Legal Business Name): SCARBROUGH CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 12/13/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 KILLOUGH RD. NORTH
WYNNE AR
72396-2465
US

IV. Provider business mailing address

PO BOX 572
WYNNE AR
72396-0572
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-8707
  • Fax: 870-238-8711
Mailing address:
  • Phone: 870-238-8707
  • Fax: 870-533-5573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1544
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP01329
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberP01329
License Number StateAR

VIII. Authorized Official

Name: TAD SCARBROUGH
Title or Position: FNP/CHIROPRACTOR/PRESIDENT
Credential: APRN, DC
Phone: 870-238-8707