=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164909081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENA PEDIATRIC CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2018
-----------------------------------------------------
Last Update Date | 06/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 HIGHWAY 71 N
-----------------------------------------------------
City | MENA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71953-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-394-5439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 HIGHWAY 71 N
-----------------------------------------------------
City | MENA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71953-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-394-5439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | ALISSA M GRANT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 479-394-5439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------