=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386743482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCARBROUGH CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 12/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 KILLOUGH RD. NORTH
-----------------------------------------------------
City | WYNNE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72396-2465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-238-8707
-----------------------------------------------------
Fax | 870-238-8711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 572
-----------------------------------------------------
City | WYNNE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72396-0572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-238-8707
-----------------------------------------------------
Fax | 870-533-5573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FNP/CHIROPRACTOR/PRESIDENT
-----------------------------------------------------
Name | TAD SCARBROUGH
-----------------------------------------------------
Credential | APRN, DC
-----------------------------------------------------
Telephone | 870-238-8707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1544
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | P01329
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | P01329
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------