=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205345154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKESIDE WALK-IN CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2017
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2230 MALVERN AVE STE E
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71901-8000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-781-3612
-----------------------------------------------------
Fax | 501-781-3618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2230 MALVERN AVE UNIT 3
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71901-8038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERNEST R ENNIS
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 501-844-7020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------