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General NPI Number Information
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NPI Number | 1174826499
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Entity Type | Organization
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Legal Business Name | CENTER FOR PEDIATRIC NEUROSCIENCE, PLLC
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Dates
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Enumeration Date | 12/08/2010
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Last Update Date | 07/10/2012
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Provider Practice Location Address
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Address Line | 2808 FOX MEADOW LN
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City | JONESBORO
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State | AR
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Zip | 72404-9346
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Country | US
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Telephone | 870-932-4245
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 814
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City | WALNUT RIDGE
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State | AR
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Zip | 72476-0814
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Country | US
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Telephone | 901-603-9936
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MR. JOB D CASPALL
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Credential | M.B.A.
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Telephone | 901-603-9936
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 11-16P
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License Number State | AR
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