=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114799483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METHENY FAMILY CARE CLINIC CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2023
-----------------------------------------------------
Last Update Date | 10/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 WATER AVE STE A
-----------------------------------------------------
City | ELM SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-9155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-844-4300
-----------------------------------------------------
Fax | 479-844-4201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 83
-----------------------------------------------------
City | ELM SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72728-0083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-844-4300
-----------------------------------------------------
Fax | 479-844-4201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LEANN W METHENY
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 479-844-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------