=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215619580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERNANDEZ FAMILY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2023
-----------------------------------------------------
Last Update Date | 05/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1424 BRADEN ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72076-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-621-2700
-----------------------------------------------------
Fax | 877-673-1707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1424 BRADEN ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72076-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-621-2700
-----------------------------------------------------
Fax | 877-673-1707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JULIAN HERNANDEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 501-621-2700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------